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NPI Code Detail

MEDICARE: JACOB D. KODRA

MEDICARE: JACOB D. KODRA
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1390200000XStudent in an Organized Health Care Education/Training Program

General Provider Information

NPI Number : 1770442394
Entity Type Code : Individual
Provider Name (Legal Business Name) : JACOB D. KODRA
Provider Business Mailing Address
First Line : 9150 W WATERTOWN PLANK RD
Second Line : UNIT 409
City : WAUWATOSA
State : WI
Zip : 53226
Country : US
Telephone Number : 619-807-1160
Fax Number :
Provider Business Practice Location Address
First Line : 9200 W WISCONSIN AVE
Second Line :
City : MILWAUKEE
State : WI
Zip : 53226-3522
Country : US
Telephone Number : 619-807-1160
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/20/2026
Last Update Date : 01/20/2026

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