Provider Demographics
NPI:1386794493
Name:MOORE, JODI MICHELLE (PA-C)
Entity type:Individual
Prefix:MS
First Name:JODI
Middle Name:MICHELLE
Last Name:MOORE
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2817 ROCK MERRITT AVE WOMACK ARMY MEDICAL CENTER
Mailing Address - Street 2:
Mailing Address - City:FORT LIBERTY
Mailing Address - State:NC
Mailing Address - Zip Code:28310-0001
Mailing Address - Country:US
Mailing Address - Phone:910-907-8922
Mailing Address - Fax:910-907-6069
Practice Address - Street 1:2817 ROCK MERRIT AVE STOP A
Practice Address - Street 2:
Practice Address - City:FORT BRAGG
Practice Address - State:NC
Practice Address - Zip Code:28310-0001
Practice Address - Country:US
Practice Address - Phone:910-907-7777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2025-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-13861363A00000X, 2081P0301X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P0301XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationBrain Injury Medicine
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1069972OtherNCCPA CERTIFICATE
AK152261OtherMEDICARE GROUP PIN
AK1255528733OtherNPI GROUP #
AK725OtherSTATE LICENSE NUMBER
MM1439391OtherDEA #
AKMD6089Medicaid
AK161782Medicare PIN
AK1386794493OtherNPI