Provider Demographics
NPI:1386916567
Name:BROADWELL, JENNIFER JO (AP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:JO
Last Name:BROADWELL
Suffix:
Gender:F
Credentials:AP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5967 MICHAUX ST
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33433-7201
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:900 N FEDERAL HWY STE 110
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33432-2753
Practice Address - Country:US
Practice Address - Phone:561-288-1325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-02
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP3041171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist