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General NPI Number Information
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NPI Number | 1053621912
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Entity Type | Individual
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Provider Name | JACOB RUSSELL MOSS
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Gender | Male
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Dates
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Enumeration Date | 10/13/2010
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Last Update Date | 07/24/2014
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Provider Practice Location Address
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Address Line | 12636 SE STARK ST PLAZA 125, BLDG J
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City | PORTLAND
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State | OR
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Zip | 97233-1058
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Country | US
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Telephone | 503-253-4600
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Fax | 503-253-4609
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Provider Business Mailing Address
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Address Line | PO BOX 82819
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City | PORTLAND
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State | OR
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Zip | 97282-0819
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Country | US
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Telephone | 801-233-5405
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number |
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License Number State |
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