Provider Demographics
NPI:1467607176
Name:BROTH, JESSICA (MA CCC SLP)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:
Last Name:BROTH
Suffix:
Gender:F
Credentials:MA CCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 HILL PARK AVE
Mailing Address - Street 2:APT 2C
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-3756
Mailing Address - Country:US
Mailing Address - Phone:516-946-3791
Mailing Address - Fax:
Practice Address - Street 1:45 HILL PARK AVE
Practice Address - Street 2:APT 2C
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-3756
Practice Address - Country:US
Practice Address - Phone:516-946-3791
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-21
Last Update Date:2010-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014924-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist