Provider Demographics
NPI:1578101846
Name:BRODA, JENNA (MED, MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:BRODA
Suffix:
Gender:F
Credentials:MED, MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 BRUIN DR
Mailing Address - Street 2:
Mailing Address - City:WELLSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26070-3064
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:29 BRUIN DR
Practice Address - Street 2:
Practice Address - City:WELLSBURG
Practice Address - State:WV
Practice Address - Zip Code:26070-3064
Practice Address - Country:US
Practice Address - Phone:304-527-1410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-17
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSLP-2031235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist