Provider Demographics
NPI:1235680547
Name:MORRISSETTE, JACLYN DIANA (PHD, ATC)
Entity Type:Individual
Prefix:MS
First Name:JACLYN
Middle Name:DIANA
Last Name:MORRISSETTE
Suffix:
Gender:F
Credentials:PHD, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:94 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:WEST MILFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:07480-4320
Mailing Address - Country:US
Mailing Address - Phone:845-430-5411
Mailing Address - Fax:
Practice Address - Street 1:300 POMPTON RD
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-2103
Practice Address - Country:US
Practice Address - Phone:973-720-2105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-21
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MT001349002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer