Provider Demographics
NPI:1801039821
Name:BROAD, JENNIFER LAUREN (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LAUREN
Last Name:BROAD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11234 ANDERSON ST
Mailing Address - Street 2:HOUSE STAFF OFFICE CP 21005
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-2804
Mailing Address - Country:US
Mailing Address - Phone:714-425-2100
Mailing Address - Fax:
Practice Address - Street 1:351 HOSPITAL RD STE 611
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-3508
Practice Address - Country:US
Practice Address - Phone:949-720-9848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-07
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA113123207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology