Provider Demographics
NPI:1104269927
Name:HERBST, JODI K (LPN)
Entity type:Individual
Prefix:
First Name:JODI
Middle Name:K
Last Name:HERBST
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:JODI
Other - Middle Name:K
Other - Last Name:GRIMWOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1716 OAKRIDGE CT
Mailing Address - Street 2:
Mailing Address - City:STOUGHTON
Mailing Address - State:WI
Mailing Address - Zip Code:53589-4938
Mailing Address - Country:US
Mailing Address - Phone:608-877-1465
Mailing Address - Fax:
Practice Address - Street 1:1716 OAKRIDGE CT
Practice Address - Street 2:
Practice Address - City:STOUGHTON
Practice Address - State:WI
Practice Address - Zip Code:53589-4938
Practice Address - Country:US
Practice Address - Phone:608-877-1465
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-10
Last Update Date:2013-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI316720-31164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse