Provider Demographics
NPI:1396022620
Name:MOORE-GARRISON, JONATHAN (LMT)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:MOORE-GARRISON
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3108 PUEBLO SAPAWE
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-2501
Mailing Address - Country:US
Mailing Address - Phone:505-252-1691
Mailing Address - Fax:
Practice Address - Street 1:1315 S SAINT FRANCIS DR
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4035
Practice Address - Country:US
Practice Address - Phone:505-252-1691
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-15
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM7706225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist