Provider Demographics
NPI:1922894955
Name:MOORE, JACINTA L (NP)
Entity type:Individual
Prefix:
First Name:JACINTA
Middle Name:L
Last Name:MOORE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JACINTA
Other - Middle Name:
Other - Last Name:INGRAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:368 MCKENZIE DR
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-6702
Mailing Address - Country:US
Mailing Address - Phone:910-723-2381
Mailing Address - Fax:
Practice Address - Street 1:368 MCKENZIE DR
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-6702
Practice Address - Country:US
Practice Address - Phone:910-723-2381
Practice Address - Fax:910-723-2381
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-16
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN334179363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily