Healthcare Provider Details

I. General information

NPI: 1568388262
Provider Name (Legal Business Name): JESSICA NICHOLE MOORE FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2026
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1805 TIFT AVE N STE D
TIFTON GA
31794-3579
US

IV. Provider business mailing address

74 SURREY CIR
TIFTON GA
31793-8490
US

V. Phone/Fax

Practice location:
  • Phone: 229-382-5554
  • Fax:
Mailing address:
  • Phone: 229-947-1544
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN-NP258792
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: