Provider Demographics
NPI:1588492490
Name:RODDICK, JASON MAICHLE (MA)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:MAICHLE
Last Name:RODDICK
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 E BADGER RD
Mailing Address - Street 2:
Mailing Address - City:FITCHBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53713-2725
Mailing Address - Country:US
Mailing Address - Phone:608-250-2512
Mailing Address - Fax:
Practice Address - Street 1:151 E BADGER RD
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:WI
Practice Address - Zip Code:53713-2725
Practice Address - Country:US
Practice Address - Phone:608-250-2512
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-23
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20619101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)