Basic Information
| Provider Information | |||||||||
| NPI: | 1487610614 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KLUMB | ||||||||
| FirstName: | JODY | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10 TOWER DR | ||||||||
| Address2: | DEAN MEDICAL CENTER | ||||||||
| City: | SUN PRAIRIE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535901239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6088253008 | ||||||||
| FaxNumber: | 6088253793 | ||||||||
| Practice Location | |||||||||
| Address1: | 10 TOWER DR | ||||||||
| Address2: | DEAN MEDICAL CENTER | ||||||||
| City: | SUN PRAIRIE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535901239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6088253008 | ||||||||
| FaxNumber: | 6088253793 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2006 | ||||||||
| LastUpdateDate: | 03/20/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 621-123 | WI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 39275300 | 05 | WI | MEDICAID | 7981 | 01 | WI | DEAN HEALTH INSURANCE | OTHER |