Provider Demographics
NPI:1790236792
Name:MOON, JENSEN M (LISW)
Entity Type:Individual
Prefix:
First Name:JENSEN
Middle Name:M
Last Name:MOON
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:JENSEN
Other - Middle Name:M
Other - Last Name:DEARMENT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LISW
Mailing Address - Street 1:625 CLEVELAND AVE NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44702-1805
Mailing Address - Country:US
Mailing Address - Phone:330-453-8252
Mailing Address - Fax:330-453-6716
Practice Address - Street 1:1341 MARKET AVE N
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44714-2605
Practice Address - Country:US
Practice Address - Phone:330-453-8252
Practice Address - Fax:330-452-4655
Is Sole Proprietor?:No
Enumeration Date:2016-10-14
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.21026861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0273660Medicaid