Provider Demographics
NPI:1538243613
Name:BERTSCH, JODI LYNN (PSYD)
Entity type:Individual
Prefix:MRS
First Name:JODI
Middle Name:LYNN
Last Name:BERTSCH
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3301 W FOREST HOME AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-2843
Mailing Address - Country:US
Mailing Address - Phone:414-389-2377
Mailing Address - Fax:414-219-5422
Practice Address - Street 1:1020 N 12TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53233
Practice Address - Country:US
Practice Address - Phone:414-219-5000
Practice Address - Fax:414-219-5422
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI70271231041C0700X
WI679124106H00000X
WI3573-57103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40996100Medicaid
WI11019700Medicaid
WI6270567OtherUBH