Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | ||
N | 2251N0400X | Physical Therapist - Neurology |
NPI | 1164022158 |
---|---|
Provider Name | Jennifer Sloop Moore |
First Address | La Grande, OR 97850-1269 |
Second Address | La Grande, OR 97850-1269 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/10/2020 |
Last Update Date | 28/10/2020 |