Provider Demographics
NPI:1104270230
Name:MOORE, JESSICA NICOLE (COTA)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:NICOLE
Last Name:MOORE
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:NICOLE
Other - Last Name:GRIGGS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:147 HAZEL TRCE
Mailing Address - Street 2:
Mailing Address - City:HAZEL GREEN
Mailing Address - State:AL
Mailing Address - Zip Code:35750-8887
Mailing Address - Country:US
Mailing Address - Phone:256-665-5619
Mailing Address - Fax:
Practice Address - Street 1:500 MARKAVIEW RD NW
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35805-3652
Practice Address - Country:US
Practice Address - Phone:256-533-8477
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-14
Last Update Date:2016-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3360224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant