Healthcare Provider Details

I. General information

NPI: 1578884789
Provider Name (Legal Business Name): JONATHAN TAD MOORE PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2010
Last Update Date: 01/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9600 VETERANS DR SW 116-A
TACOMA WA
98493-0003
US

IV. Provider business mailing address

9600 VETERANS DR SW 116-A
TACOMA WA
98493-0003
US

V. Phone/Fax

Practice location:
  • Phone: 253-583-1771
  • Fax:
Mailing address:
  • Phone: 253-583-1771
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY 60586639
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: