Provider Demographics
NPI:1063080554
Name:MOORE, JACOB BRADLEY
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:BRADLEY
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 1:500 N KEENE ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-8104
Mailing Address - Country:US
Mailing Address - Phone:573-874-2030
Mailing Address - Fax:573-449-0253
Practice Address - Street 1:500 N KEENE ST
Practice Address - Street 2:SUITE 103
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-8104
Practice Address - Country:US
Practice Address - Phone:573-874-2030
Practice Address - Fax:573-449-0253
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-11
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021020987152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist