Healthcare Provider Details

I. General information

NPI: 1649417957
Provider Name (Legal Business Name): JACQUELINE MAE MOYER MPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2009
Last Update Date: 01/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7950 MARTIN LOOP #9200
FORT BENNING GA
31905-5647
US

IV. Provider business mailing address

5013 STONE PARK DR
COLUMBUS GA
31909-9124
US

V. Phone/Fax

Practice location:
  • Phone: 706-615-7161
  • Fax:
Mailing address:
  • Phone: 706-610-7704
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number008888
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: