Provider Demographics
NPI:1710741442
Name:MOXLEY, JETT DISPOTO (LPCA)
Entity Type:Individual
Prefix:
First Name:JETT
Middle Name:DISPOTO
Last Name:MOXLEY
Suffix:
Gender:F
Credentials:LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 HARMAC DR
Mailing Address - Street 2:
Mailing Address - City:EAST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06513-1210
Mailing Address - Country:US
Mailing Address - Phone:862-227-5904
Mailing Address - Fax:
Practice Address - Street 1:111 NEW HAVEN AVE
Practice Address - Street 2:
Practice Address - City:DERBY
Practice Address - State:CT
Practice Address - Zip Code:06418-2197
Practice Address - Country:US
Practice Address - Phone:475-439-9639
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-13
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT6718101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional