Basic Information
| Provider Information | |||||||||
| NPI: | 1306517768 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | TUCKER | ||||||||
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| Credential: | OTR/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1266 PRISCILLA DR | ||||||||
| Address2: | |||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951294324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6503914041 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1949 GRANT RD | ||||||||
| Address2: | |||||||||
| City: | MOUNTAIN VIEW | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940403217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6509682990 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2021 | ||||||||
| LastUpdateDate: | 09/24/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 19759 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.