Provider Demographics
NPI:1194878207
Name:BROAD, JENNIFER OTYLIA (DC)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:OTYLIA
Last Name:BROAD
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91-1072 OPAEHUNA ST
Mailing Address - Street 2:
Mailing Address - City:EWA BEACH
Mailing Address - State:HI
Mailing Address - Zip Code:96706-3565
Mailing Address - Country:US
Mailing Address - Phone:808-676-6855
Mailing Address - Fax:
Practice Address - Street 1:803 KAMEHAMEHA HWY STE 309
Practice Address - Street 2:
Practice Address - City:PEARL CITY
Practice Address - State:HI
Practice Address - Zip Code:96782-2638
Practice Address - Country:US
Practice Address - Phone:808-456-5553
Practice Address - Fax:808-455-6520
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDC 657111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor