Healthcare Provider Details

I. General information

NPI: 1073430989
Provider Name (Legal Business Name): JENNIFER MOORE LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2026
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 RAVENNA DR
CENTERTON AR
72719-7719
US

IV. Provider business mailing address

430 RAVENNA DR
CENTERTON AR
72719-7719
US

V. Phone/Fax

Practice location:
  • Phone: 530-264-6279
  • Fax:
Mailing address:
  • Phone: 530-264-6279
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number1617659
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: