Healthcare Provider Details

I. General information

NPI: 1023271962
Provider Name (Legal Business Name): JENNIFER E MOORE MS, RDN, LDN, CSR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2008
Last Update Date: 01/10/2022
Certification Date: 01/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3870 LISCOTT RD
SOUTHAVEN MS
38672-6780
US

IV. Provider business mailing address

3870 LISCOTT RD
SOUTHAVEN MS
38672-6780
US

V. Phone/Fax

Practice location:
  • Phone: 702-533-2259
  • Fax:
Mailing address:
  • Phone: 702-533-2259
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License NumberLDN0000001086
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: