Healthcare Provider Details

I. General information

NPI: 1992680177
Provider Name (Legal Business Name): JILLIAN MARGUERITE MOORE CRM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2025
Last Update Date: 08/07/2025
Certification Date: 08/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 SE HAILEY AVE STE 204
PENDLETON OR
97801-3072
US

IV. Provider business mailing address

1275 W MADRONA AVE APT B
HERMISTON OR
97838-1445
US

V. Phone/Fax

Practice location:
  • Phone: 541-663-4104
  • Fax: 541-663-4142
Mailing address:
  • Phone: 541-314-5570
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number25-CRM-4289
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: