Healthcare Provider Details

I. General information

NPI: 1437063039
Provider Name (Legal Business Name): JAZZMIN DESTINEE MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2026
Last Update Date: 09/30/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6232 N 7TH ST STE 101
PHOENIX AZ
85014-1850
US

IV. Provider business mailing address

24711 136TH RD
ROSEDALE NY
11422-1624
US

V. Phone/Fax

Practice location:
  • Phone: 928-504-4700
  • Fax:
Mailing address:
  • Phone: 516-309-2605
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number331800
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: