Provider Demographics
NPI:1992170211
Name:MOON, JIMMY
Entity type:Individual
Prefix:
First Name:JIMMY
Middle Name:
Last Name:MOON
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 1:16541 SWEETWATER DR
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:DE
Mailing Address - Zip Code:19968-3062
Mailing Address - Country:US
Mailing Address - Phone:302-500-0950
Mailing Address - Fax:
Practice Address - Street 1:16541 SWEETWATER DR
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:DE
Practice Address - Zip Code:19968-3062
Practice Address - Country:US
Practice Address - Phone:302-500-0950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-11
Last Update Date:2015-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE2015102773171WH0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications