Provider Demographics
NPI:1932138807
Name:HOLBROOK, JODI L (MD)
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:L
Last Name:HOLBROOK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5287
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61125-0287
Mailing Address - Country:US
Mailing Address - Phone:815-484-6300
Mailing Address - Fax:815-395-2021
Practice Address - Street 1:1235 N MULFORD RD STE 210
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-3879
Practice Address - Country:US
Practice Address - Phone:815-484-6300
Practice Address - Fax:815-395-2021
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036084288207Q00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036084288Medicaid
L7991Medicare ID - Type Unspecified
IL036084288Medicaid