Provider Demographics
NPI:1548624786
Name:MOORE, JENNIFER (LMT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3696 GARDEN CT
Mailing Address - Street 2:
Mailing Address - City:GROVE CITY
Mailing Address - State:OH
Mailing Address - Zip Code:43123-2906
Mailing Address - Country:US
Mailing Address - Phone:614-801-1307
Mailing Address - Fax:614-801-9095
Practice Address - Street 1:4261 KIMBERLY PKWY
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43232-7226
Practice Address - Country:US
Practice Address - Phone:614-755-7700
Practice Address - Fax:614-755-9634
Is Sole Proprietor?:No
Enumeration Date:2016-04-13
Last Update Date:2016-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.018968225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist