Provider Demographics
NPI:1750360293
Name:MOORE, JEFFREY L (PHD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:L
Last Name:MOORE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8870 BURNING TREE RD
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32514-5602
Mailing Address - Country:US
Mailing Address - Phone:850-474-1147
Mailing Address - Fax:850-474-1147
Practice Address - Street 1:220 HOVEY RD
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32508-1044
Practice Address - Country:US
Practice Address - Phone:850-452-2157
Practice Address - Fax:850-452-2690
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-12
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810001376103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist