MEDICARE: MISS JESSICA MOORE FNP-C

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	363LF0000X	Family Nurse Practitioner	RN229030	GA

General Provider Information

NPI Number	:	1912514886
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS JESSICA MOORE FNP-C

Provider Business Mailing Address
First Line	:	3451 COBB PKWY NW STE 4
Second Line	:
City	:	ACWORTH
State	:	GA
Zip	:	30101-4000
Country	:	US
Telephone Number	:	678-574-5678
Fax Number	:	678-574-5605

Provider Business Practice Location Address
First Line	:	3451 COBB PKWY NW STE 4
Second Line	:
City	:	ACWORTH
State	:	GA
Zip	:	30101-4000
Country	:	US
Telephone Number	:	678-574-5678
Fax Number	:	678-574-5605

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

Provider Enumeration Date	:	09/25/2020
Last Update Date	:	09/25/2020

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