Provider Demographics
NPI:1871809301
Name:MOON, JASPER (CPM, LMT)
Entity type:Individual
Prefix:
First Name:JASPER
Middle Name:
Last Name:MOON
Suffix:
Gender:F
Credentials:CPM, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6744 SE MAPLEHURST RD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-1938
Mailing Address - Country:US
Mailing Address - Phone:971-678-2842
Mailing Address - Fax:
Practice Address - Street 1:6744 SE MAPLEHURST RD
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-1938
Practice Address - Country:US
Practice Address - Phone:971-678-2842
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
176B00000X, 374J00000X
OR18114225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No176B00000XOther Service ProvidersMidwife
No374J00000XNursing Service Related ProvidersDoula