Provider Demographics
NPI:1457666174
Name:MOSETI, JADE (COTA)
Entity Type:Individual
Prefix:MS
First Name:JADE
Middle Name:
Last Name:MOSETI
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1328 GEORGE ST
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54603-2457
Mailing Address - Country:US
Mailing Address - Phone:608-782-1220
Mailing Address - Fax:
Practice Address - Street 1:2600 WARD AVE
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-7424
Practice Address - Country:US
Practice Address - Phone:608-787-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-18
Last Update Date:2010-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4719-027174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist