Provider Demographics
NPI:1629081898
Name:MOEN, JONAS O (MD)
Entity type:Individual
Prefix:
First Name:JONAS
Middle Name:O
Last Name:MOEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:36065 SANTA FE AVE
Mailing Address - Street 2:CAFBHS 3RD FLOOR
Mailing Address - City:FORT CAVAZOS
Mailing Address - State:TX
Mailing Address - Zip Code:76544
Mailing Address - Country:US
Mailing Address - Phone:254-287-1866
Mailing Address - Fax:254-618-1004
Practice Address - Street 1:36065 SANTA FE AVE
Practice Address - Street 2:
Practice Address - City:FORT CAVAZOS
Practice Address - State:TX
Practice Address - Zip Code:76544-4752
Practice Address - Country:US
Practice Address - Phone:254-287-1866
Practice Address - Fax:254-618-1004
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2025-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH64442084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0002LPOtherBC/BS
TX162008OtherVALUE OPTIONS
TX041249603Medicaid
TX041249603Medicaid