Provider Demographics
NPI:1720501455
Name:MOORE, JERRY LEO JR
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:LEO
Last Name:MOORE
Suffix:JR
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 1:10408 PRESTON VINEYARD DR
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75035-8027
Mailing Address - Country:US
Mailing Address - Phone:504-654-7331
Mailing Address - Fax:
Practice Address - Street 1:10408 PRESTON VINEYARD DR
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75035
Practice Address - Country:US
Practice Address - Phone:504-654-7331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)