Provider Demographics
NPI:1770759516
Name:MOONEY, JUSTIN HENRY
Entity type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:HENRY
Last Name:MOONEY
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:JAKE
Other - Middle Name:HENRY
Other - Last Name:MOONEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1053 N D ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92410-3521
Mailing Address - Country:US
Mailing Address - Phone:909-886-1691
Mailing Address - Fax:909-881-8694
Practice Address - Street 1:555 N PERRIS BLVD
Practice Address - Street 2:
Practice Address - City:PERRIS
Practice Address - State:CA
Practice Address - Zip Code:92571-2811
Practice Address - Country:US
Practice Address - Phone:909-886-1691
Practice Address - Fax:909-881-8694
Is Sole Proprietor?:No
Enumeration Date:2008-05-01
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health