Provider Demographics
NPI:1649216045
Name:BREHM, JODI L (MD)
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:L
Last Name:BREHM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JODI
Other - Middle Name:L
Other - Last Name:GROSSMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:10400 75TH ST
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-7884
Mailing Address - Country:US
Mailing Address - Phone:262-648-5600
Mailing Address - Fax:262-948-5735
Practice Address - Street 1:10400 75TH ST
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142
Practice Address - Country:US
Practice Address - Phone:262-648-5600
Practice Address - Fax:262-948-5735
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036112238208600000X
WI52096208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036112238Medicaid
WI35354900Medicaid
WII57301Medicare UPIN