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General NPI Number Information
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NPI Number | 1235680547
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Entity Type | Individual
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Provider Name | JACLYN DIANA MORRISSETTE PHD, ATC
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Gender | Female
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Dates
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Enumeration Date | 10/21/2016
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Last Update Date | 01/12/2021
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Provider Practice Location Address
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Address Line | 300 POMPTON RD
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City | WAYNE
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State | NJ
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Zip | 07470-2103
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Country | US
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Telephone | 973-720-2105
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Fax |
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Provider Business Mailing Address
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Address Line | 94 BROADWAY
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City | WEST MILFORD
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State | NJ
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Zip | 07480-4320
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Country | US
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Telephone | 845-430-5411
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 25MT00134900
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License Number State | NJ
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