MEDICARE: JACOB MOON MS, LMFT, LPC

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	106H00000X	Marriage & Family Therapist	4101007162	MI
2	101YM0800X	Mental Health Counselor	6401224962	MI

General Provider Information

NPI Number	:	1831655422
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACOB MOON MS, LMFT, LPC

Provider Business Mailing Address
First Line	:	1809 COLLEGE AVE SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49507-2621
Country	:	US
Telephone Number	:	616-209-8854
Fax Number	:

Provider Business Practice Location Address
First Line	:	146 MONROE CENTER ST NW STE 1104
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49503-2820
Country	:	US
Telephone Number	:	616-626-1082
Fax Number	:

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

Provider Enumeration Date	:	02/19/2019
Last Update Date	:	09/30/2025

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