Provider Demographics
NPI:1437313046
Name:BRODERSON, JENNIFER DIANE (LMT)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:DIANE
Last Name:BRODERSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:74-5620 PALANI RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:KAILUA KONA
Mailing Address - State:HI
Mailing Address - Zip Code:96740-3640
Mailing Address - Country:US
Mailing Address - Phone:808-329-7797
Mailing Address - Fax:808-329-2748
Practice Address - Street 1:74-5620 PALANI RD
Practice Address - Street 2:SUITE 102
Practice Address - City:KAILUA KONA
Practice Address - State:HI
Practice Address - Zip Code:96740-3640
Practice Address - Country:US
Practice Address - Phone:808-329-7797
Practice Address - Fax:808-329-2748
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-12
Last Update Date:2008-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMAT10080174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist