Provider Demographics
NPI:1922360064
Name:BRENNER, JODI LYNN (MSED)
Entity Type:Individual
Prefix:MS
First Name:JODI
Middle Name:LYNN
Last Name:BRENNER
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:MS
Other - First Name:JODI
Other - Middle Name:LYNN
Other - Last Name:ELION
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSED
Mailing Address - Street 1:218 WASHINGTON AVE APT C12
Mailing Address - Street 2:C12
Mailing Address - City:CEDARHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11516-1510
Mailing Address - Country:US
Mailing Address - Phone:917-741-1006
Mailing Address - Fax:
Practice Address - Street 1:218 WASHINGTON AVE APT C12
Practice Address - Street 2:C12
Practice Address - City:CEDARHURST
Practice Address - State:NY
Practice Address - Zip Code:11516-1510
Practice Address - Country:US
Practice Address - Phone:917-741-1006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-14
Last Update Date:2012-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist