Individual
JACOB RUSSELL MOSS
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
12636 SE STARK ST, PLAZA 125, BLDG J, PORTLAND, OR 97233-1058
(503) 253-4600
(503) 253-4609
Mailing address
PO BOX 82819, PORTLAND, OR 97282-0819
(801) 233-5405
Taxonomy
Speciality
Code
Description
License number
State
104100000X
Social Worker
Primary
—
—
Other
Enumeration date
10/13/2010
Last updated
07/24/2014
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