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General NPI Number Information
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NPI Number | 1346008844
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Entity Type | Individual
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Provider Name | JACOB RYAN MOORE
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Gender | Male
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Dates
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Enumeration Date | 03/08/2024
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Last Update Date | 03/08/2024
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Provider Practice Location Address
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Address Line | 10821 FAIR OAKS BLVD
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City | FAIR OAKS
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State | CA
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Zip | 95628-7214
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Country | US
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Telephone | 916-903-7028
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Fax |
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Provider Business Mailing Address
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Address Line | 2609 K ST APT 11
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City | SACRAMENTO
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State | CA
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Zip | 95816-5112
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Country | US
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Telephone | 916-230-5613
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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 | 164X00000X
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Taxonomy Name | Licensed Vocational Nurse
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License Number | 722770
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License Number State | CA
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