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NPI Code Detail

MEDICARE: MR. JERRY DON MOORE LBP

MEDICARE: MR. JERRY DON MOORE LBP
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
1101YM0800XMental Health Counselor0142OK

General Provider Information

NPI Number : 1528370947
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. JERRY DON MOORE LBP
Provider Business Mailing Address
First Line : 1315 W CEDAR AVE
Second Line :
City : DUNCAN
State : OK
Zip : 73533-4057
Country : US
Telephone Number : 580-475-7162
Fax Number :
Provider Business Practice Location Address
First Line : 7 N 8TH ST
Second Line :
City : DUNCAN
State : OK
Zip : 73533-4601
Country : US
Telephone Number : 580-475-7162
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/14/2010
Last Update Date : 07/14/2010

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Directions to “ MR. JERRY DON MOORE LBP” Practice Location

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