MEDICARE: JESSICA MORA ATC, CSCS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	AL1012	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	AL1012	OTHER	FL	ATHLETIC TRAINER

General Provider Information

NPI Number	:	1417005646
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA MORA ATC, CSCS

Provider Business Mailing Address
First Line	:	5237 SW 40TH AVE
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33314-6501
Country	:	US
Telephone Number	:	305-298-7966
Fax Number	:	954-584-8190

Provider Business Practice Location Address
First Line	:	5237 SW 40TH AVE
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33314-6501
Country	:	US
Telephone Number	:	305-298-7966
Fax Number	:	954-584-8190

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/05/2007
Last Update Date	:	07/08/2007

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