Provider Demographics
NPI:1679384820
Name:MOORE, JENNIFER VANITA (LMBT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:VANITA
Last Name:MOORE
Suffix:
Gender:F
Credentials:LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 S COOK ST
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:NC
Mailing Address - Zip Code:27298-2719
Mailing Address - Country:US
Mailing Address - Phone:336-653-8577
Mailing Address - Fax:
Practice Address - Street 1:128 W SWANNANOA AVE
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:NC
Practice Address - Zip Code:27298
Practice Address - Country:US
Practice Address - Phone:336-653-8577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-16
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6407225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist