Healthcare Provider Details

I. General information

NPI: 1740866516
Provider Name (Legal Business Name): JESSICA MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2021
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1665 SARATOGA WAY
EDMOND OK
73003-3552
US

IV. Provider business mailing address

3018 NW 48TH ST
OKLAHOMA CITY OK
73112-6030
US

V. Phone/Fax

Practice location:
  • Phone: 405-880-5120
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberCF922
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: