Healthcare Provider Details

I. General information

NPI: 1750360293
Provider Name (Legal Business Name): JEFFREY L MOORE PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2006
Last Update Date: 07/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 HOVEY RD
PENSACOLA FL
32508-1044
US

IV. Provider business mailing address

8870 BURNING TREE RD
PENSACOLA FL
32514-5602
US

V. Phone/Fax

Practice location:
  • Phone: 850-452-2157
  • Fax: 850-452-2690
Mailing address:
  • Phone: 850-474-1147
  • Fax: 850-474-1147

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number0810001376
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: