Provider Demographics
NPI:1013555002
Name:BROADNAX, JASMINE TAYLOR (BSL)
Entity Type:Individual
Prefix:
First Name:JASMINE
Middle Name:TAYLOR
Last Name:BROADNAX
Suffix:
Gender:F
Credentials:BSL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1119 WYNNBROOK RD
Mailing Address - Street 2:
Mailing Address - City:SECANE
Mailing Address - State:PA
Mailing Address - Zip Code:19018-3516
Mailing Address - Country:US
Mailing Address - Phone:215-834-2765
Mailing Address - Fax:
Practice Address - Street 1:467 CREAMERY WAY
Practice Address - Street 2:
Practice Address - City:EXTON
Practice Address - State:PA
Practice Address - Zip Code:19341-2508
Practice Address - Country:US
Practice Address - Phone:610-594-0278
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-20
Last Update Date:2019-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAAA0001811151106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty