Individual
SARA N JETTAWI
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
LPC
Contact information
Practice address
2108 63RD ST, KENOSHA, WI 53143-4454
(262) 652-2406
Mailing address
6233 39TH AVE, KENOSHA, WI 53142-7015
(262) 654-1004
Taxonomy
Speciality
Code
Description
License number
State
101Y00000X
Counselor
Primary
10456-125
WI
101YP2500X
Professional Counselor
10456-125
WI
104100000X
Social Worker
5035-226
WI
Other
Enumeration date
10/07/2021
Last updated
06/04/2024
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