Healthcare Provider Details

I. General information

NPI: 1538243613
Provider Name (Legal Business Name): JODI LYNN BERTSCH PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 11/22/2021
Certification Date: 11/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 N 12TH ST
MILWAUKEE WI
53233
US

IV. Provider business mailing address

3301 W FOREST HOME AVE
MILWAUKEE WI
53215-2843
US

V. Phone/Fax

Practice location:
  • Phone: 414-219-5000
  • Fax: 414-219-5422
Mailing address:
  • Phone: 414-389-2377
  • Fax: 414-219-5422

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number3573-57
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number7027123
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number679124
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: