Provider Demographics
NPI:1407595341
Name:MOON, JAMEKA
Entity Type:Individual
Prefix:
First Name:JAMEKA
Middle Name:
Last Name:MOON
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:DEPT LA 22763
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91185-0001
Mailing Address - Country:US
Mailing Address - Phone:866-523-4268
Mailing Address - Fax:
Practice Address - Street 1:1519 JOHNSON FERRY RD STE 100
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-6410
Practice Address - Country:US
Practice Address - Phone:866-523-4268
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-31
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician