Provider Demographics
NPI:1508118233
Name:MOORE, JONATHAN D (LMT)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:D
Last Name:MOORE
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 1:434 E HILL ST
Mailing Address - Street 2:
Mailing Address - City:NAVASOTA
Mailing Address - State:TX
Mailing Address - Zip Code:77868-2428
Mailing Address - Country:US
Mailing Address - Phone:832-248-5677
Mailing Address - Fax:
Practice Address - Street 1:434 E HILL ST
Practice Address - Street 2:
Practice Address - City:NAVASOTA
Practice Address - State:TX
Practice Address - Zip Code:77868-2428
Practice Address - Country:US
Practice Address - Phone:832-248-5677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-04
Last Update Date:2012-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT109187225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist