Provider Demographics
NPI:1831436096
Name:MOORE, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1411 N BECKLEY AVE
Mailing Address - Street 2:PAVILION III, SUITE 474
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75203-1259
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1411 N BECKLEY AVE
Practice Address - Street 2:PAVILION III, SUITE 474
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75203-1259
Practice Address - Country:US
Practice Address - Phone:214-393-5007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-08
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant