Healthcare Provider Details

I. General information

NPI: 1518871144
Provider Name (Legal Business Name): CHARNEDRA JASMINE MOORE CPO
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: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 S DAMEN AVE
CHICAGO IL
60612-3728
US

IV. Provider business mailing address

820 S DAMEN AVE
CHICAGO IL
60612-3728
US

V. Phone/Fax

Practice location:
  • Phone: 312-569-7113
  • Fax:
Mailing address:
  • Phone: 312-569-7113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code222Z00000X
TaxonomyOrthotist
License NumberCPO03465
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License NumberCPO03465
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: