Provider Demographics
NPI:1336644582
Name:BROADDUS, JENNY LEE (LPC-S)
Entity Type:Individual
Prefix:MRS
First Name:JENNY
Middle Name:LEE
Last Name:BROADDUS
Suffix:
Gender:F
Credentials:LPC-S
Other - Prefix:
Other - First Name:JENNY
Other - Middle Name:LEE
Other - Last Name:FULLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3160 BROWNSTONE PL
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77706-7449
Mailing Address - Country:US
Mailing Address - Phone:409-504-2545
Mailing Address - Fax:
Practice Address - Street 1:8150 N. MAJOR DR.
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77706
Practice Address - Country:US
Practice Address - Phone:409-898-0702
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-29
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX58968101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional