Provider Demographics
NPI:1841605797
Name:MOORE, JEROME
Entity type:Individual
Prefix:MR
First Name:JEROME
Middle Name:
Last Name:MOORE
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 1:55 PAULA DR
Mailing Address - Street 2:
Mailing Address - City:PORTERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30014-5013
Mailing Address - Country:US
Mailing Address - Phone:770-896-1413
Mailing Address - Fax:
Practice Address - Street 1:3044 ASHLY FOREST DR
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-4524
Practice Address - Country:US
Practice Address - Phone:770-896-1413
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-29
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QA0600X
GACN0030028021376K00000X
GAE029658146N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, BasicGroup - Single Specialty
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day CareGroup - Single Specialty
No376K00000XNursing Service Related ProvidersNurse's Aide