Provider Demographics
NPI:1366940033
Name:JACKSON-MOORE, ALFREDO
Entity type:Individual
Prefix:
First Name:ALFREDO
Middle Name:
Last Name:JACKSON-MOORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11416 ROSALIE DR
Mailing Address - Street 2:
Mailing Address - City:FORT WASHINGTON
Mailing Address - State:MD
Mailing Address - Zip Code:20744-2615
Mailing Address - Country:US
Mailing Address - Phone:202-725-3080
Mailing Address - Fax:
Practice Address - Street 1:11416 ROSALIE DR
Practice Address - Street 2:
Practice Address - City:FORT WASHINGTON
Practice Address - State:MD
Practice Address - Zip Code:20744-2615
Practice Address - Country:US
Practice Address - Phone:202-725-3080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-29
Last Update Date:2018-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant