Provider Demographics
NPI:1962086165
Name:MOORE, JENNIFER (AGACNP-BC, DNP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:AGACNP-BC, DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5089 W DUCKHORN DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84009-8145
Mailing Address - Country:US
Mailing Address - Phone:801-362-4227
Mailing Address - Fax:
Practice Address - Street 1:1660 E MURRAY HOLLADAY RD
Practice Address - Street 2:
Practice Address - City:HOLLADAY
Practice Address - State:UT
Practice Address - Zip Code:84117-5008
Practice Address - Country:US
Practice Address - Phone:801-419-0705
Practice Address - Fax:801-606-7902
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-12
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7014826-4405363L00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program