Healthcare Provider Details

I. General information

NPI: 1366625444
Provider Name (Legal Business Name): JENNIFER BROADWATER KINGERY D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2007
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

191 W UNION ST STE 127
ATHENS OH
45701-2732
US

IV. Provider business mailing address

PO BOX 7527
DUBLIN OH
43017-0727
US

V. Phone/Fax

Practice location:
  • Phone: 740-592-7010
  • Fax:
Mailing address:
  • Phone: 740-592-7010
  • Fax: 740-592-7011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number34.015734
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number34.015734
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number03244
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: