Provider Demographics
NPI:1235675976
Name:BROUD, JANE (LCSW)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:
Last Name:BROUD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:JANE
Other - Middle Name:
Other - Last Name:COAD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8495 CRATER LAKE HWY
Mailing Address - Street 2:
Mailing Address - City:WHITE CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97503-3011
Mailing Address - Country:US
Mailing Address - Phone:541-826-2111
Mailing Address - Fax:541-830-7528
Practice Address - Street 1:8495 CRATER LAKE HWY
Practice Address - Street 2:
Practice Address - City:WHITE CITY
Practice Address - State:OR
Practice Address - Zip Code:97503-3011
Practice Address - Country:US
Practice Address - Phone:541-826-2111
Practice Address - Fax:541-830-7528
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-18
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR71801041C0700X
OHI 16007891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical