Basic Information
| Provider Information | |||||||||
| NPI: | 1275513830 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | E. | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2455 HARRINGTON DR | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300334903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043156081 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1984 PEACHTREE RD NW STE 515 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303095219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043511745 | ||||||||
| FaxNumber: | 4043517121 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2006 | ||||||||
| LastUpdateDate: | 01/27/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367H00000X | 003360 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |
ID Information
| ID | Type | State | Issuer | Description | 100000534A | 05 | GA | MEDICAID |