Provider Demographics
NPI:1144258807
Name:BRODERICK, JENNIFER L (CAREGIVER)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:BRODERICK
Suffix:
Gender:F
Credentials:CAREGIVER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:44904-1113
Mailing Address - Country:US
Mailing Address - Phone:419-884-1302
Mailing Address - Fax:419-884-8398
Practice Address - Street 1:79 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:OH
Practice Address - Zip Code:44904-1113
Practice Address - Country:US
Practice Address - Phone:419-884-1302
Practice Address - Fax:419-884-8398
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2539088171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2539088Medicaid