Healthcare Provider Details

I. General information

NPI: 1033611256
Provider Name (Legal Business Name): JACQUELINE MOORE FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2018
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

314 MAIN ST STE D
MONTICELLO MS
39654-3702
US

IV. Provider business mailing address

1314 ZETUS RD NW
BROOKHAVEN MS
39601-8309
US

V. Phone/Fax

Practice location:
  • Phone: 601-587-4304
  • Fax:
Mailing address:
  • Phone: 601-757-5621
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number902473
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number859952
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: