Provider Demographics
NPI:1225846348
Name:GORE, JAY
Entity type:Individual
Prefix:
First Name:JAY
Middle Name:
Last Name:GORE
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 1:1005 PARKWAY DR UNIT B
Mailing Address - Street 2:
Mailing Address - City:CABOOL
Mailing Address - State:MO
Mailing Address - Zip Code:65689-7430
Mailing Address - Country:US
Mailing Address - Phone:417-551-2202
Mailing Address - Fax:
Practice Address - Street 1:502 S 3RD ST B
Practice Address - Street 2:
Practice Address - City:OZARK
Practice Address - State:MO
Practice Address - Zip Code:65721
Practice Address - Country:US
Practice Address - Phone:417-299-4605
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-20
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021016011225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist