Provider Demographics
NPI:1083450761
Name:MOONSTONE MENTAL HEALTH
Entity type:Organization
Organization Name:MOONSTONE MENTAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PMHNP-BC
Authorized Official - Prefix:
Authorized Official - First Name:JENNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MSN
Authorized Official - Phone:503-443-8339
Mailing Address - Street 1:7110 SW FIR LOOP STE 145
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8031
Mailing Address - Country:US
Mailing Address - Phone:503-389-5882
Mailing Address - Fax:
Practice Address - Street 1:7110 SW FIR LOOP STE 145
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-8031
Practice Address - Country:US
Practice Address - Phone:503-389-5882
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-02
Last Update Date:2025-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty