Healthcare Provider Details

I. General information

NPI: 1134876113
Provider Name (Legal Business Name): JENNIFER MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2022
Last Update Date: 03/30/2022
Certification Date: 03/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 EZZARD CHARLES DR
CINCINNATI OH
45214-2525
US

IV. Provider business mailing address

8561 NORTHPORT DR
CINCINNATI OH
45255-3274
US

V. Phone/Fax

Practice location:
  • Phone: 513-381-6672
  • Fax:
Mailing address:
  • Phone: 513-419-9392
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.504987
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: