Provider Demographics
NPI:1245051697
Name:MOORE, JOLYNN (LMT)
Entity type:Individual
Prefix:
First Name:JOLYNN
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 NICHOLSON AVE
Mailing Address - Street 2:
Mailing Address - City:PORT BYRON
Mailing Address - State:NY
Mailing Address - Zip Code:13140-3326
Mailing Address - Country:US
Mailing Address - Phone:315-604-8091
Mailing Address - Fax:
Practice Address - Street 1:2645 ERIE DR
Practice Address - Street 2:
Practice Address - City:WEEDSPORT
Practice Address - State:NY
Practice Address - Zip Code:13166-3214
Practice Address - Country:US
Practice Address - Phone:315-604-8091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-18
Last Update Date:2024-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2987229225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist