Provider Demographics
NPI:1629426200
Name:BRIN, JODI ALLISON (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JODI
Middle Name:ALLISON
Last Name:BRIN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:JODI
Other - Middle Name:ALLISON
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:14135 N CEDARBURG RD
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53097-1416
Mailing Address - Country:US
Mailing Address - Phone:262-377-2006
Mailing Address - Fax:
Practice Address - Street 1:14135 N CEDARBURG RD
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53097-1416
Practice Address - Country:US
Practice Address - Phone:262-377-2006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-24
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3346-57103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical