Provider Demographics
NPI:1235221052
Name:MOON, JONI MARIE (PSYD)
Entity type:Individual
Prefix:MRS
First Name:JONI
Middle Name:MARIE
Last Name:MOON
Suffix:
Gender:
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 SW CORBETH LN
Mailing Address - Street 2:
Mailing Address - City:TROUTDALE
Mailing Address - State:OR
Mailing Address - Zip Code:97060-3140
Mailing Address - Country:US
Mailing Address - Phone:503-891-0749
Mailing Address - Fax:
Practice Address - Street 1:502 N MAIN AVE
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-7236
Practice Address - Country:US
Practice Address - Phone:503-891-0749
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1637103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR164936Medicaid
OR164936Medicaid