Provider Demographics
NPI:1609988948
Name:MOON, JENNIFER H (PHD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:H
Last Name:MOON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2542 E TOWNER ST
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85716-2117
Mailing Address - Country:US
Mailing Address - Phone:520-529-8210
Mailing Address - Fax:520-844-8722
Practice Address - Street 1:2542 E TOWNER ST
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85716-2117
Practice Address - Country:US
Practice Address - Phone:520-529-8210
Practice Address - Fax:520-844-8722
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3575103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist