Provider Demographics
NPI:1497761464
Name:BROY, JEFF LEE
Entity Type:Individual
Prefix:MR
First Name:JEFF
Middle Name:LEE
Last Name:BROY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1805 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-1157
Mailing Address - Country:US
Mailing Address - Phone:618-998-1689
Mailing Address - Fax:618-998-1789
Practice Address - Street 1:1805 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-1157
Practice Address - Country:US
Practice Address - Phone:618-998-1689
Practice Address - Fax:618-998-1789
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2767237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist