Provider Demographics
NPI:1255947313
Name:MORETTI, JACKIE L (SAC-IT, BS)
Entity type:Individual
Prefix:MISS
First Name:JACKIE
Middle Name:L
Last Name:MORETTI
Suffix:
Gender:F
Credentials:SAC-IT, BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5109 WORLD DAIRY DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53718-3807
Mailing Address - Country:US
Mailing Address - Phone:608-242-0220
Mailing Address - Fax:608-242-0220
Practice Address - Street 1:5109 WORLD DAIRY DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53718-3807
Practice Address - Country:US
Practice Address - Phone:608-242-0220
Practice Address - Fax:608-242-1166
Is Sole Proprietor?:No
Enumeration Date:2020-09-23
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19266-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)