Provider Demographics
NPI:1093533895
Name:MOORE, JEREMIAH JERROD
Entity type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:JERROD
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 1:2606 CROCKETT DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27858-6811
Mailing Address - Country:US
Mailing Address - Phone:252-214-1365
Mailing Address - Fax:
Practice Address - Street 1:2606 CROCKETT DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27858-6811
Practice Address - Country:US
Practice Address - Phone:252-214-1365
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-30
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program