Provider Demographics
NPI:1861769705
Name:MOSHER, JEREMIAH (DC)
Entity type:Individual
Prefix:DR
First Name:JEREMIAH
Middle Name:
Last Name:MOSHER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1908 GREENWOOD DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-2430
Mailing Address - Country:US
Mailing Address - Phone:314-401-0088
Mailing Address - Fax:
Practice Address - Street 1:1908 GREENWOOD DR
Practice Address - Street 2:SUITE B
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-2430
Practice Address - Country:US
Practice Address - Phone:314-401-0088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-21
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011037826111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor