Provider Demographics
NPI:1285079814
Name:BRODERICK, JILLIAN (PTA)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:
Last Name:BRODERICK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 JACOBS AVE
Mailing Address - Street 2:
Mailing Address - City:BEVERLY
Mailing Address - State:MA
Mailing Address - Zip Code:01915-4126
Mailing Address - Country:US
Mailing Address - Phone:978-922-9239
Mailing Address - Fax:
Practice Address - Street 1:7 RESERVOIR RD
Practice Address - Street 2:
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915-5501
Practice Address - Country:US
Practice Address - Phone:978-524-0333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-09
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7896225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant