MEDICARE: JENNA MARIE MOON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	36772	CA

General Provider Information

NPI Number	:	1336854736
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNA MARIE MOON

Provider Business Mailing Address
First Line	:	200 S MAIN ST STE 130-528
Second Line	:
City	:	SEBASTOPOL
State	:	CA
Zip	:	95472-4284
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1500 PETALUMA BLVD S
Second Line	:
City	:	PETALUMA
State	:	CA
Zip	:	94952-5545
Country	:	US
Telephone Number	:	707-765-8488
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/19/2023
Last Update Date	:	06/06/2026

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Directions to “ JENNA MARIE MOON ” Practice Location

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