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General NPI Number Information
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NPI Number | 1023981909
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Entity Type | Individual
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Provider Name | JENNA BROOKLYN MOORE
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Gender | Female
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Dates
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Enumeration Date | 09/25/2025
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Last Update Date | 12/03/2025
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Provider Practice Location Address
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Address Line | 800 5TH AVE STE 300
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City | FORT WORTH
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State | TX
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Zip | 76104-7303
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Country | US
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Telephone | 817-250-5690
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Fax | 817-878-5321
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Provider Business Mailing Address
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Address Line | 5001 STATE HIGHWAY 114 APT 3311
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City | NORTHLAKE
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State | TX
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Zip | 76262-2278
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Country | US
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Telephone | 812-621-7977
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number |
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | PA19726
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License Number State | TX
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