Provider Demographics
NPI:1407602642
Name:MOSS, JACQUELINE DENISE
Entity type:Individual
Prefix:MISS
First Name:JACQUELINE
Middle Name:DENISE
Last Name:MOSS
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 1:2100 N EASTERN AVE STE 8
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-5684
Mailing Address - Country:US
Mailing Address - Phone:802-393-8007
Mailing Address - Fax:
Practice Address - Street 1:2100 N EASTERN AVE STE 8EE
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-5683
Practice Address - Country:US
Practice Address - Phone:802-393-8007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-29
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter
No1744P3200XOther Service ProvidersSpecialistProsthetics Case Management