Provider Demographics
NPI:1710491667
Name:MOODY, JASON
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:MOODY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:468 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:DAMARISCOTTA
Mailing Address - State:ME
Mailing Address - Zip Code:04543-4677
Mailing Address - Country:US
Mailing Address - Phone:207-563-2886
Mailing Address - Fax:207-778-0003
Practice Address - Street 1:468 MAIN STREET
Practice Address - Street 2:
Practice Address - City:DAMARISCOTTA
Practice Address - State:ME
Practice Address - Zip Code:04543-4677
Practice Address - Country:US
Practice Address - Phone:207-563-2886
Practice Address - Fax:207-778-0003
Is Sole Proprietor?:No
Enumeration Date:2017-11-29
Last Update Date:2017-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDL394237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist