Provider Demographics
NPI:1629081898
Name:MOEN, JONAS O (MD)
Entity Type:Individual
Prefix:
First Name:JONAS
Middle Name:O
Last Name:MOEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 W HWY 6
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76712
Mailing Address - Country:US
Mailing Address - Phone:254-776-0001
Mailing Address - Fax:254-776-0026
Practice Address - Street 1:1000 W HWY 6
Practice Address - Street 2:SUITE 100
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712
Practice Address - Country:US
Practice Address - Phone:254-776-0001
Practice Address - Fax:254-776-0026
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH64442084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0002LPOtherBC/BS
TX041249603Medicaid
TX162008OtherVALUE OPTIONS
TX041249603Medicaid