1528114709 NPI number — MR. JONATHAN MOORE CLOUD LCSW

Table of content: (NPI 1215910674)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528114709 NPI number — MR. JONATHAN MOORE CLOUD LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLOUD
Provider First Name:
JONATHAN
Provider Middle Name:
MOORE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1528114709
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2206 SOMERS AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BURLINGTON
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27215-3338
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-585-0140
Provider Business Mailing Address Fax Number:
919-603-5090

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 ORANGE ST STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OXFORD
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27565-3249
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-212-9048
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/28/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  C000512 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 23153 . This is a "NC HEALTH CHOICE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 6002795 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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