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General NPI Number Information
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NPI Number | 1770442394
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Entity Type | Individual
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Provider Name | JACOB D. KODRA
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Gender | Male
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Dates
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Enumeration Date | 01/20/2026
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Last Update Date | 01/20/2026
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Provider Practice Location Address
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Address Line | 9200 W WISCONSIN AVE
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City | MILWAUKEE
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State | WI
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Zip | 53226-3522
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Country | US
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Telephone | 619-807-1160
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Fax |
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Provider Business Mailing Address
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Address Line | 9150 W WATERTOWN PLANK RD UNIT 409
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City | WAUWATOSA
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State | WI
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Zip | 53226
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Country | US
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Telephone | 619-807-1160
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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