Healthcare Provider Details

I. General information

NPI: 1891353199
Provider Name (Legal Business Name): JONATHAN MARCEL MOSES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2019
Last Update Date: 05/10/2022
Certification Date: 05/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

295 N 3855 E
RIGBY ID
83442-5124
US

IV. Provider business mailing address

2275 W BROADWAY ST
IDAHO FALLS ID
83402-2902
US

V. Phone/Fax

Practice location:
  • Phone: 208-745-5205
  • Fax:
Mailing address:
  • Phone: 208-524-7400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-42172
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: