Healthcare Provider Details

I. General information

NPI: 1417430471
Provider Name (Legal Business Name): JONATHAN BYREL MOORE-NORTHROP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JONATHAN MOORE

II. Dates (important events)

Enumeration Date: 09/14/2018
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 BRUSH ST
UKIAH CA
95482-3424
US

IV. Provider business mailing address

100 W SMITH ST APT 1
UKIAH CA
95482-4357
US

V. Phone/Fax

Practice location:
  • Phone: 707-462-6290
  • Fax: 707-468-6427
Mailing address:
  • Phone: 707-462-6290
  • Fax: 707-468-6427

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number53107
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: