Healthcare Provider Details

I. General information

NPI: 1306055207
Provider Name (Legal Business Name): JERI H MOORE M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 09/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1907 W SYCAMORE ST
KOKOMO IN
46901-5148
US

IV. Provider business mailing address

10330 N MERIDIAN ST
INDIANAPOLIS IN
46290-1024
US

V. Phone/Fax

Practice location:
  • Phone: 765-456-5900
  • Fax:
Mailing address:
  • Phone: 317-319-7666
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: