Provider Demographics
NPI:1568046472
Name:MOON, JENNIFER ANN
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANN
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 1:413 SECURITY BLVD
Mailing Address - Street 2:STE D
Mailing Address - City:SECURITY
Mailing Address - State:CO
Mailing Address - Zip Code:80911
Mailing Address - Country:US
Mailing Address - Phone:719-321-4863
Mailing Address - Fax:
Practice Address - Street 1:413 SECURITY BLVD
Practice Address - Street 2:STE D
Practice Address - City:SECURITY
Practice Address - State:CO
Practice Address - Zip Code:80911
Practice Address - Country:US
Practice Address - Phone:171-932-1486
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-06
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT0019004225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist