Healthcare Provider Details

I. General information

NPI: 1336854736
Provider Name (Legal Business Name): JENNA MARIE MOON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JENNIFER MOON PSYD

II. Dates (important events)

Enumeration Date: 01/19/2023
Last Update Date: 06/06/2026
Certification Date: 06/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 PETALUMA BLVD S
PETALUMA CA
94952-5545
US

IV. Provider business mailing address

200 S MAIN ST STE 130-528
SEBASTOPOL CA
95472-4284
US

V. Phone/Fax

Practice location:
  • Phone: 707-765-8488
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number36772
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: