Basic Information
| Provider Information | |||||||||
| NPI: | 1992161871 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | JAMIE | ||||||||
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| NamePrefix: | MRS. | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2836 CROSS CREEK DR | ||||||||
| Address2: | |||||||||
| City: | GREEN COVE SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320436234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9045054840 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4565 US HIGHWAY 17 STE 200 | ||||||||
| Address2: | |||||||||
| City: | FLEMING ISLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320034823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9046340640 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2016 | ||||||||
| LastUpdateDate: | 10/10/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | PTA 26354 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.