Healthcare Provider Details

I. General information

NPI: 1861320038
Provider Name (Legal Business Name): JACOB RAYMOND MOORE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2026
Last Update Date: 05/09/2026
Certification Date: 05/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

182 SW ACADEMY ST
DALLAS OR
97338-1996
US

IV. Provider business mailing address

30288 WALNUT DR SW
ALBANY OR
97321-9454
US

V. Phone/Fax

Practice location:
  • Phone: 503-962-3928
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: