=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952601130
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JONATHAN DAVID MOSS MSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/22/2010
-----------------------------------------------------
Last Update Date | 04/07/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 399 W. KAWILI ST. #202
-----------------------------------------------------
City | HILO
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96720-4086
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-657-8484
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 110 ALAE ST
-----------------------------------------------------
City | HILO
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96720-2507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-657-8484
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 4194
-----------------------------------------------------
License Number State | HI
-----------------------------------------------------