Basic Information
| Provider Information | |||||||||
| NPI: | 1386250033 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | JENNY | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 153 VINE CREEK PT | ||||||||
| Address2: | |||||||||
| City: | ACWORTH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301015917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037339703 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3150 N COBB PKWY STE 150 | ||||||||
| Address2: | |||||||||
| City: | KENNESAW | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301521009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6785746868 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/18/2020 | ||||||||
| LastUpdateDate: | 09/18/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT014591 | GA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.