Provider Demographics
NPI:1306233093
Name:MOORE, JACKEE NIKITA
Entity type:Individual
Prefix:
First Name:JACKEE
Middle Name:NIKITA
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3271 LODWICK DR NW
Mailing Address - Street 2:APT 4
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44485-1565
Mailing Address - Country:US
Mailing Address - Phone:330-240-8366
Mailing Address - Fax:
Practice Address - Street 1:3271 LODWICK DR NW
Practice Address - Street 2:APT 4
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44485-1565
Practice Address - Country:US
Practice Address - Phone:330-240-8366
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-20
Last Update Date:2015-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0115639Medicaid