Provider Demographics
NPI:1578884789
Name:MOORE, JONATHAN TAD (PHD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:TAD
Last Name:MOORE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9600 VETERANS DR SW
Mailing Address - Street 2:116-A
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98493-0003
Mailing Address - Country:US
Mailing Address - Phone:253-583-1771
Mailing Address - Fax:
Practice Address - Street 1:9600 VETERANS DR SW
Practice Address - Street 2:116-A
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98493-0003
Practice Address - Country:US
Practice Address - Phone:253-583-1771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-22
Last Update Date:2016-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY 60586639103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist