Provider Demographics
NPI:1679945000
Name:MOORE, JACQUELINE FAITH (PA-C)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:FAITH
Last Name:MOORE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:FITCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 1189
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-1189
Mailing Address - Country:US
Mailing Address - Phone:541-768-7999
Mailing Address - Fax:
Practice Address - Street 1:400 HICKORY ST NW STE 303
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97321-1700
Practice Address - Country:US
Practice Address - Phone:541-812-5275
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-26
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA175138363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant