Provider Demographics
NPI:1306836903
Name:MONIOT, JENNIFER MOON
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MOON
Last Name:MONIOT
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:PSC 78 BOX 1654
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96326-0017
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:360 LILLY RD NE
Practice Address - Street 2:#A
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5430
Practice Address - Country:US
Practice Address - Phone:360-486-0640
Practice Address - Fax:360-486-0641
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2016-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28559225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0321478OtherL & I
VAD000Medicare UPIN
WAG8926341Medicare PIN