1679203863 NPI number — DR. JENNIFER NICOLE MOONEY DMD

Table of content: DR. JENNIFER NICOLE MOONEY DMD (NPI 1679203863)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679203863 NPI number — DR. JENNIFER NICOLE MOONEY DMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOONEY
Provider First Name:
JENNIFER
Provider Middle Name:
NICOLE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DMD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1679203863
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/13/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
150 LIVE OAKS BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PEARL
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39208-8071
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
769-428-0054
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
209 RIVERWIND DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PEARL
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39208-5653
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-936-6161
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/13/2022

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  4287-22 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)