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General NPI Number Information
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NPI Number | 1144258807
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Entity Type | Individual
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Provider Name | JENNIFER L BRODERICK CAREGIVER
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Gender | Female
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Dates
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Enumeration Date | 06/29/2006
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Last Update Date | 07/09/2007
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Provider Practice Location Address
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Address Line | 79 W MAIN ST
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City | LEXINGTON
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State | OH
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Zip | 44904-1113
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Country | US
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Telephone | 419-884-1302
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Fax | 419-884-8398
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Provider Business Mailing Address
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Address Line | 79 W MAIN ST
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City | LEXINGTON
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State | OH
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Zip | 44904-1113
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Country | US
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Telephone | 419-884-1302
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Fax | 419-884-8398
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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 | 171W00000X
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Taxonomy Name | Contractor
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License Number | 2539088
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License Number State | OH
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