Provider Demographics
NPI:1265766943
Name:MOREAU, GENNIFER LYNN
Entity type:Individual
Prefix:
First Name:GENNIFER
Middle Name:LYNN
Last Name:MOREAU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1623 MILL BAY RD STE 2
Mailing Address - Street 2:
Mailing Address - City:KODIAK
Mailing Address - State:AK
Mailing Address - Zip Code:99615-6200
Mailing Address - Country:US
Mailing Address - Phone:907-486-5011
Mailing Address - Fax:907-486-5019
Practice Address - Street 1:1623 MILL BAY RD STE 2
Practice Address - Street 2:
Practice Address - City:KODIAK
Practice Address - State:AK
Practice Address - Zip Code:99615-6200
Practice Address - Country:US
Practice Address - Phone:907-486-5011
Practice Address - Fax:907-486-5019
Is Sole Proprietor?:No
Enumeration Date:2009-09-28
Last Update Date:2009-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator