Healthcare Provider Details

I. General information

NPI: 1700780640
Provider Name (Legal Business Name): JASON MOORE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2026
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10306 ELLISON CIR
OMAHA NE
68134-1024
US

IV. Provider business mailing address

10682 LAFAYETTE PLZ APT 121
OMAHA NE
68114-2058
US

V. Phone/Fax

Practice location:
  • Phone: 402-953-3240
  • Fax:
Mailing address:
  • Phone: 531-777-1746
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: