Provider Demographics
NPI:1306517768
Name:MOORE, JONATHAN TUCKER (OTR/L)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:TUCKER
Last Name:MOORE
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1266 PRISCILLA DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95129-4324
Mailing Address - Country:US
Mailing Address - Phone:650-391-4041
Mailing Address - Fax:
Practice Address - Street 1:1949 GRANT RD
Practice Address - Street 2:
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94040-3217
Practice Address - Country:US
Practice Address - Phone:650-968-2990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-24
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19759225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist