Provider Demographics
NPI:1881067197
Name:MORRIS, JERRY (SAC-IT)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:MORRIS
Suffix:
Gender:M
Credentials:SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1303 CHATHAM ST
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53402-4947
Mailing Address - Country:US
Mailing Address - Phone:262-589-1392
Mailing Address - Fax:262-598-1395
Practice Address - Street 1:1303 CHATHAM ST
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53402-4947
Practice Address - Country:US
Practice Address - Phone:262-598-1392
Practice Address - Fax:262-598-1395
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-09
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17429-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)