Provider Demographics
NPI:1629273008
Name:MOON, JACKI L (LMT)
Entity Type:Individual
Prefix:
First Name:JACKI
Middle Name:L
Last Name:MOON
Suffix:
Gender:F
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:P.O. BOX 1061
Mailing Address - Street 2:
Mailing Address - City:LAKE STEVENS
Mailing Address - State:WA
Mailing Address - Zip Code:98258
Mailing Address - Country:US
Mailing Address - Phone:425-397-4900
Mailing Address - Fax:425-397-6900
Practice Address - Street 1:10519 20TH ST. SE
Practice Address - Street 2:SUITE # 1
Practice Address - City:LAKE STEVENS
Practice Address - State:WA
Practice Address - Zip Code:98258
Practice Address - Country:US
Practice Address - Phone:425-397-4900
Practice Address - Fax:425-397-6900
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-18
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00004663174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist