Provider Demographics
NPI:1851574586
Name:MOORE, JON THOMAS (MPT, OCS)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:THOMAS
Last Name:MOORE
Suffix:
Gender:M
Credentials:MPT, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5355 NORMA AVE SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97306-1596
Mailing Address - Country:US
Mailing Address - Phone:971-239-3272
Mailing Address - Fax:
Practice Address - Street 1:156 FRONT ST NE STE 180
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-3479
Practice Address - Country:US
Practice Address - Phone:971-239-3272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-17
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5566225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist