Provider Demographics
NPI:1215628284
Name:MORENO, JASON TY
Entity type:Individual
Prefix:MR
First Name:JASON
Middle Name:TY
Last Name:MORENO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3214 PERIDOT AVE APT 210
Mailing Address - Street 2:
Mailing Address - City:AMES
Mailing Address - State:IA
Mailing Address - Zip Code:50010-1216
Mailing Address - Country:US
Mailing Address - Phone:562-457-9675
Mailing Address - Fax:
Practice Address - Street 1:3214 PERIDOT AVE APT 210
Practice Address - Street 2:
Practice Address - City:AMES
Practice Address - State:IA
Practice Address - Zip Code:50010-1216
Practice Address - Country:US
Practice Address - Phone:562-457-9675
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-18
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer