Provider Demographics
NPI:1528542990
Name:BROADWATER, JENNIFER CHU (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:CHU
Last Name:BROADWATER
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 AUSTIN HWY APT 5406
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78209-4973
Mailing Address - Country:US
Mailing Address - Phone:208-477-8446
Mailing Address - Fax:
Practice Address - Street 1:1223 AUSTIN HWY
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78209-4854
Practice Address - Country:US
Practice Address - Phone:210-202-3579
Practice Address - Fax:210-202-3589
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-20
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX62549183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist