Provider Demographics
NPI:1124522834
Name:MOORE, JORDAN ALEXANDER
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:ALEXANDER
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 1:4032 KNOLLBROOK DR NW
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILE
Mailing Address - State:AL
Mailing Address - Zip Code:35810-1832
Mailing Address - Country:US
Mailing Address - Phone:256-694-5688
Mailing Address - Fax:
Practice Address - Street 1:4032 KNOLLBROOK DR NW
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35810-1832
Practice Address - Country:US
Practice Address - Phone:256-694-5688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-19
Last Update Date:2018-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy