Provider Demographics
NPI:1083047997
Name:MOON, JEFF A (LMFT)
Entity Type:Individual
Prefix:
First Name:JEFF
Middle Name:A
Last Name:MOON
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3599 HOMESTEAD RD
Mailing Address - Street 2:
Mailing Address - City:RESCUE
Mailing Address - State:CA
Mailing Address - Zip Code:95672-9547
Mailing Address - Country:US
Mailing Address - Phone:530-591-5720
Mailing Address - Fax:207-692-9374
Practice Address - Street 1:13405 FOLSOM BLVD STE 210
Practice Address - Street 2:
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-4738
Practice Address - Country:US
Practice Address - Phone:916-621-2750
Practice Address - Fax:916-621-2750
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-14
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA104390106H00000X
101YM0800X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health