Individual
JONATHAN MOORE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
8075 MALL PKWY, STE. 101-334, LITHONIA, GA 30038-6993
(678) 508-1935
(770) 323-1935
Mailing address
2542 YOUNG RD, STONE MOUNTAIN, GA 30088-4204
(678) 508-1935
(770) 323-1935
Taxonomy
Speciality
Code
Description
License number
State
171M00000X
Case Manager/Care Coordinator
Primary
—
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
743527131A
—
GA
Enumeration date
03/24/2012
Last updated
03/24/2012
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