Provider Demographics
NPI:1326582149
Name:MORAL, JEAN
Entity type:Individual
Prefix:
First Name:JEAN
Middle Name:
Last Name:MORAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10012 W CAPITOL DR STE 101
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53222-1300
Mailing Address - Country:US
Mailing Address - Phone:414-810-4844
Mailing Address - Fax:
Practice Address - Street 1:10012 W CAPITOL DR STE 101
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53222-1300
Practice Address - Country:US
Practice Address - Phone:414-810-4844
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-13
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI568004101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)