Provider Demographics
NPI:1902385628
Name:DALEY, JODIE MARIE (RTR)
Entity Type:Individual
Prefix:MRS
First Name:JODIE
Middle Name:MARIE
Last Name:DALEY
Suffix:
Gender:F
Credentials:RTR
Other - Prefix:MS
Other - First Name:JODIE
Other - Middle Name:MARIE
Other - Last Name:MEKKA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2626 N 76TH ST
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53213-1137
Mailing Address - Country:US
Mailing Address - Phone:414-943-7342
Mailing Address - Fax:
Practice Address - Street 1:2626 N 76TH ST
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53213-1137
Practice Address - Country:US
Practice Address - Phone:414-943-7342
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-13
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5744-142247100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist