Provider Demographics
NPI:1437281326
Name:HERTACH, JODI MAE (RN)
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:MAE
Last Name:HERTACH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 COCHRAN ST
Mailing Address - Street 2:
Mailing Address - City:HUTCHINSON
Mailing Address - State:KS
Mailing Address - Zip Code:67501-2535
Mailing Address - Country:US
Mailing Address - Phone:620-662-6723
Mailing Address - Fax:
Practice Address - Street 1:1715 E 23RD AVE
Practice Address - Street 2:
Practice Address - City:HUTCHINSON
Practice Address - State:KS
Practice Address - Zip Code:67502-1105
Practice Address - Country:US
Practice Address - Phone:620-665-2240
Practice Address - Fax:620-665-2276
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS13-31734-022163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse