Provider Demographics
NPI:1760633622
Name:MOORE, JEREMY (AAOT)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:MOORE
Suffix:
Gender:M
Credentials:AAOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:740 NE 53RD AVE APT 33
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-3164
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3550 SE WOODWARD ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-1552
Practice Address - Country:US
Practice Address - Phone:503-517-8663
Practice Address - Fax:503-943-4994
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-08
Last Update Date:2008-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor