Provider Demographics
NPI:1114186996
Name:BROADHURST, JENNIE TARA (BA DEGREE)
Entity Type:Individual
Prefix:MRS
First Name:JENNIE
Middle Name:TARA
Last Name:BROADHURST
Suffix:
Gender:F
Credentials:BA DEGREE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 MOODY CT
Mailing Address - Street 2:COUNTY OF VENTURA CONEJO VALLEY MENTAL HEALTH
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91360
Mailing Address - Country:US
Mailing Address - Phone:805-587-5328
Mailing Address - Fax:
Practice Address - Street 1:72 MOODY CT
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-6067
Practice Address - Country:US
Practice Address - Phone:805-587-5328
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-05
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator