Provider Demographics
NPI:1831655422
Name:MOON, JACOB (MS, LMFT)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:MOON
Suffix:
Gender:M
Credentials:MS, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 OTTAWA AVE NW STE 405
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2648
Mailing Address - Country:US
Mailing Address - Phone:616-209-8450
Mailing Address - Fax:616-317-6976
Practice Address - Street 1:80 OTTAWA AVE NW STE 405
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2648
Practice Address - Country:US
Practice Address - Phone:616-209-8450
Practice Address - Fax:616-317-6976
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-19
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4101007162106H00000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist