Provider Demographics
NPI:1033750930
Name:MOREAU, JONATHON BRADLEY (MA)
Entity Type:Individual
Prefix:MR
First Name:JONATHON
Middle Name:BRADLEY
Last Name:MOREAU
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5200 NELSON RD APT 1311
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-0818
Mailing Address - Country:US
Mailing Address - Phone:337-532-4831
Mailing Address - Fax:
Practice Address - Street 1:2519 RYAN ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-7323
Practice Address - Country:US
Practice Address - Phone:337-491-0800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-01
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1-19-38169103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst