Provider Demographics
NPI:1447912480
Name:JETTAWI, SARA N (LPC)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:N
Last Name:JETTAWI
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:SARA
Other - Middle Name:
Other - Last Name:SALZMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:6233 39TH AVE
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-7015
Mailing Address - Country:US
Mailing Address - Phone:262-654-1004
Mailing Address - Fax:
Practice Address - Street 1:2108 63RD ST
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53143-4454
Practice Address - Country:US
Practice Address - Phone:262-652-2406
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-07
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10456-125101YP2500X, 101Y00000X
WI5035-226104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No104100000XBehavioral Health & Social Service ProvidersSocial Worker