Provider Demographics
NPI:1104064443
Name:BROBST, JENNIFER BOOTHE (PHD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:BOOTHE
Last Name:BROBST
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 387
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:IL
Mailing Address - Zip Code:60101-0387
Mailing Address - Country:US
Mailing Address - Phone:630-495-8702
Mailing Address - Fax:630-495-8703
Practice Address - Street 1:18W100 22ND ST
Practice Address - Street 2:SUITE 130
Practice Address - City:OAKBROOK TERRACE
Practice Address - State:IL
Practice Address - Zip Code:60181-4499
Practice Address - Country:US
Practice Address - Phone:630-424-9204
Practice Address - Fax:630-424-9208
Is Sole Proprietor?:No
Enumeration Date:2009-01-24
Last Update Date:2009-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071007544103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical