Healthcare Provider Details

I. General information

NPI: 1235221052
Provider Name (Legal Business Name): JONI MARIE MOON PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 02/27/2025
Certification Date: 02/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 N MAIN AVE
GRESHAM OR
97030-7236
US

IV. Provider business mailing address

2700 SW CORBETH LN
TROUTDALE OR
97060-3140
US

V. Phone/Fax

Practice location:
  • Phone: 503-891-0749
  • Fax:
Mailing address:
  • Phone: 503-891-0749
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1637
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1637
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: