Provider Demographics
NPI:1316541204
Name:BROADWAY, JESSICA LYNN (ARRT RT(R)(CT)(M))
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:BROADWAY
Suffix:
Gender:F
Credentials:ARRT RT(R)(CT)(M)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3626 BEECHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86406-7239
Mailing Address - Country:US
Mailing Address - Phone:573-382-9704
Mailing Address - Fax:
Practice Address - Street 1:12033 W AGENCY AVE
Practice Address - Street 2:
Practice Address - City:PARKER
Practice Address - State:AZ
Practice Address - Zip Code:85344
Practice Address - Country:US
Practice Address - Phone:928-669-3379
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-23
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ316222085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology