Provider Demographics
NPI:1871639591
Name:MOORE, JANA LAURIE (OTR)
Entity type:Individual
Prefix:
First Name:JANA
Middle Name:LAURIE
Last Name:MOORE
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:JANA
Other - Middle Name:LAURIE
Other - Last Name:TOWNSEND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR
Mailing Address - Street 1:107 KELLY ST
Mailing Address - Street 2:
Mailing Address - City:DEXTER
Mailing Address - State:MO
Mailing Address - Zip Code:63841-1980
Mailing Address - Country:US
Mailing Address - Phone:573-624-6913
Mailing Address - Fax:
Practice Address - Street 1:107 KELLY ST
Practice Address - Street 2:
Practice Address - City:DEXTER
Practice Address - State:MO
Practice Address - Zip Code:63841-1980
Practice Address - Country:US
Practice Address - Phone:573-614-1136
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO002769225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics