Provider Demographics
NPI:1558116087
Name:MOORE, JONATHAN (PRS)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:MOORE
Suffix:
Gender:
Credentials:PRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 CROWNE POINT PL
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45241-5427
Mailing Address - Country:US
Mailing Address - Phone:513-743-7628
Mailing Address - Fax:
Practice Address - Street 1:865 S PATTERSON BLVD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45402-2624
Practice Address - Country:US
Practice Address - Phone:937-966-4673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-18
Last Update Date:2025-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 106S00000X
OHAPS.004937175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician