Provider Demographics
NPI:1508759309
Name:MORA, JACK WALTER
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:WALTER
Last Name:MORA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8251 PATHFINDER LOOP APT 617
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-8793
Mailing Address - Country:US
Mailing Address - Phone:239-322-7732
Mailing Address - Fax:
Practice Address - Street 1:8251 PATHFINDER LOOP APT 617
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-8793
Practice Address - Country:US
Practice Address - Phone:239-322-7732
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-30
Last Update Date:2025-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9555145163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse