Provider Demographics
NPI:1144492927
Name:MOON, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MOON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1703 N MCMULLEN BOOTH RD UNIT 1440
Mailing Address - Street 2:
Mailing Address - City:SAFETY HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34695-9653
Mailing Address - Country:US
Mailing Address - Phone:727-485-4660
Mailing Address - Fax:
Practice Address - Street 1:2421 NEANDER LANE
Practice Address - Street 2:
Practice Address - City:SAFETY HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34695
Practice Address - Country:US
Practice Address - Phone:727-485-4660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-01
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSS951103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool