Provider Demographics
NPI:1891956736
Name:LOTHIAN, JENNIFER BROOKS (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:BROOKS
Last Name:LOTHIAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:WINNEBAGO
Mailing Address - State:WI
Mailing Address - Zip Code:54985-0009
Mailing Address - Country:US
Mailing Address - Phone:920-235-4910
Mailing Address - Fax:920-237-2041
Practice Address - Street 1:400 W RIVER DR
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53090-1567
Practice Address - Country:US
Practice Address - Phone:262-338-2717
Practice Address - Fax:262-338-9767
Is Sole Proprietor?:No
Enumeration Date:2008-06-23
Last Update Date:2018-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI359572084P0800X
AK24882084P0800X
AZ172462084P0800X
HI118232084P0800X
IN010418892084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
C99901Medicare UPIN