Provider Demographics
NPI:1235259011
Name:BROYLES, JENNIFER S (MD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:S
Last Name:BROYLES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:SUE
Other - Last Name:HEAD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:790 DUNLAWTON AVE STE E
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-4222
Mailing Address - Country:US
Mailing Address - Phone:386-760-1877
Mailing Address - Fax:386-760-2791
Practice Address - Street 1:790 DUNLAWTON AVE STE E
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-4222
Practice Address - Country:US
Practice Address - Phone:386-760-1877
Practice Address - Fax:386-760-2791
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2025-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME131695207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1508624Medicaid
TN30003921Medicare PIN
TN1508624Medicaid