=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215477542
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SARA JANE ALLEE-JATTA CSAC, CSIT, SAP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/06/2017
-----------------------------------------------------
Last Update Date | 11/14/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1955 W BROADWAY
-----------------------------------------------------
City | MONONA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53713-3700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-750-5416
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1955 W BROADWAY
-----------------------------------------------------
City | MONONA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53713-3700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-750-5416
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 16292-132
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------