MEDICARE: JACEN MOORE ATC

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	2255A2300X	Athletic Trainer	1534	AZ

General Provider Information

NPI Number	:	1962910158
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACEN MOORE ATC

Provider Business Mailing Address
First Line	:	610 E ROOSEVELT ST UNIT 142
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85004-1983
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1166 E WARNER RD STE 101
Second Line	:
City	:	GILBERT
State	:	AZ
Zip	:	85296-3065
Country	:	US
Telephone Number	:	480-415-4214
Fax Number	:	480-415-4214

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

Provider Enumeration Date	:	01/22/2018
Last Update Date	:	01/22/2018

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