Provider Demographics
NPI:1386250033
Name:MOORE, JENNY LYNN (PT)
Entity type:Individual
Prefix:
First Name:JENNY
Middle Name:LYNN
Last Name:MOORE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 VINE CREEK PT
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101-5917
Mailing Address - Country:US
Mailing Address - Phone:203-733-9703
Mailing Address - Fax:
Practice Address - Street 1:3150 N COBB PKWY STE 150
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30152-1009
Practice Address - Country:US
Practice Address - Phone:678-574-6868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-18
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT014591225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist