Basic Information
| Provider Information | |||||||||
| NPI: | 1760910699 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | JANE | ||||||||
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| Credential: | GC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6626 E 75TH ST STE 500 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462502890 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3176211647 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7120 CLEARVISTA DR STE 5900 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462561714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3176215395 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2017 | ||||||||
| LastUpdateDate: | 06/04/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 170300000X | 74000181A | IN | Y | Other Service Providers | Genetic Counselor, MS |
ID Information
| ID | Type | State | Issuer | Description | 300008014 | 05 | IN | MEDICAID | 74000181A | 01 | IN | INDIANA GENETIC COUNSELOR LICENSE | OTHER | K02-66-8390 | 01 | KS | DRIVERS LICENSE | OTHER |