Provider Demographics
NPI:1770786352
Name:MOORE, JODI LYNN (OTD, OTR/L, CHT)
Entity type:Individual
Prefix:
First Name:JODI
Middle Name:LYNN
Last Name:MOORE
Suffix:
Gender:F
Credentials:OTD, OTR/L, CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7485 MISSION VALLEY RD
Mailing Address - Street 2:STE 104A
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-4422
Mailing Address - Country:US
Mailing Address - Phone:336-545-5000
Mailing Address - Fax:336-545-5020
Practice Address - Street 1:3200 NORTHLINE AVE
Practice Address - Street 2:STE 160
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27408-7616
Practice Address - Country:US
Practice Address - Phone:336-545-5000
Practice Address - Fax:336-545-5020
Is Sole Proprietor?:No
Enumeration Date:2007-06-08
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC 008606225X00000X
CA18401225XH1200X
NC6526225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6526OtherNC BOARD OCCUPATIONAL THERAPY
NCPTAN Q40482AOtherMEDICARE PTAN