Provider Demographics
NPI:1316684566
Name:MORENO, JONATHAN ALEXANDER
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:ALEXANDER
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 1:5006 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH GATE
Mailing Address - State:CA
Mailing Address - Zip Code:90280-6434
Mailing Address - Country:US
Mailing Address - Phone:323-907-2889
Mailing Address - Fax:
Practice Address - Street 1:2550 E FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91107-3406
Practice Address - Country:US
Practice Address - Phone:626-701-4747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-18
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator