Provider Demographics
NPI:1558441717
Name:BRODERICK, JINNY RENEE (LCSW)
Entity Type:Individual
Prefix:
First Name:JINNY
Middle Name:RENEE
Last Name:BRODERICK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 E STATE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-3404
Mailing Address - Country:US
Mailing Address - Phone:260-481-2700
Mailing Address - Fax:260-481-2709
Practice Address - Street 1:909 E STATE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-3404
Practice Address - Country:US
Practice Address - Phone:260-481-2700
Practice Address - Fax:260-481-2709
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2010-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34005183A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical