MEDICARE: JENNIFER JANE MOORE GC

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	170300000X	Genetic Counselor (M.S.)	74000181A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	74000181A	OTHER	IN	INDIANA GENETIC COUNSELOR LICENSE
3	K02-66-8390	OTHER	KS	DRIVERS LICENSE

General Provider Information

NPI Number	:	1760910699
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER JANE MOORE GC

Provider Business Mailing Address
First Line	:	6626 E 75TH ST STE 500
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46250-2890
Country	:	US
Telephone Number	:	317-621-1647
Fax Number	:

Provider Business Practice Location Address
First Line	:	7120 CLEARVISTA DR STE 5900
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46256-1714
Country	:	US
Telephone Number	:	317-621-5395
Fax Number	:

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

Provider Enumeration Date	:	05/23/2017
Last Update Date	:	06/04/2021

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