MEDICARE: JENNIFER L BRODERICK CAREGIVER

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
1	171W00000X	Contractor	2539088	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1144258807
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER L BRODERICK CAREGIVER

Provider Business Mailing Address
First Line	:	79 W MAIN ST
Second Line	:
City	:	LEXINGTON
State	:	OH
Zip	:	44904-1113
Country	:	US
Telephone Number	:	419-884-1302
Fax Number	:	419-884-8398

Provider Business Practice Location Address
First Line	:	79 W MAIN ST
Second Line	:
City	:	LEXINGTON
State	:	OH
Zip	:	44904-1113
Country	:	US
Telephone Number	:	419-884-1302
Fax Number	:	419-884-8398

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/29/2006
Last Update Date	:	07/09/2007

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