Provider Demographics
NPI:1326172990
Name:BROUGHTON, JENNIFER ELIZABETH (COTAL)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ELIZABETH
Last Name:BROUGHTON
Suffix:
Gender:F
Credentials:COTAL
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:ELIZABETH
Other - Last Name:STARON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTAL
Mailing Address - Street 1:327 NAUVOO RD
Mailing Address - Street 2:
Mailing Address - City:MORRIS
Mailing Address - State:PA
Mailing Address - Zip Code:16938-9568
Mailing Address - Country:US
Mailing Address - Phone:570-353-2718
Mailing Address - Fax:
Practice Address - Street 1:10 SHERMAN ST
Practice Address - Street 2:
Practice Address - City:WELLSBORO
Practice Address - State:PA
Practice Address - Zip Code:16901-1829
Practice Address - Country:US
Practice Address - Phone:570-724-1811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOP003316L224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant