Provider Demographics
NPI:1770469603
Name:MOORE, JACOB A (PT)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:A
Last Name:MOORE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:7849 TRAMWAY BLVD NE STE A
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87122-2529
Mailing Address - Country:US
Mailing Address - Phone:505-485-4176
Mailing Address - Fax:505-212-0786
Practice Address - Street 1:240 S CAMINO DEL PUEBLO
Practice Address - Street 2:
Practice Address - City:BERNALILLO
Practice Address - State:NM
Practice Address - Zip Code:87004-6076
Practice Address - Country:US
Practice Address - Phone:505-373-2836
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-14
Last Update Date:2025-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist