Healthcare Provider Details

I. General information

NPI: 1508131855
Provider Name (Legal Business Name): JENNIFER LYNN MORENO MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2012
Last Update Date: 03/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21425 SPRING ST
UNION GROVE WI
53182-9707
US

IV. Provider business mailing address

21425 SPRING ST
UNION GROVE WI
53182-9707
US

V. Phone/Fax

Practice location:
  • Phone: 262-878-7011
  • Fax: 262-878-7024
Mailing address:
  • Phone: 262-878-7011
  • Fax: 262-878-7024

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number126683-121
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: