Provider Demographics
NPI:1821052457
Name:BROACH, JENNIFER L (PHD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:L
Last Name:BROACH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 VETERANS DR
Mailing Address - Street 2:VA MEDICAL CENTER (116A4-LD)
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40502
Mailing Address - Country:US
Mailing Address - Phone:859-281-3817
Mailing Address - Fax:859-281-3919
Practice Address - Street 1:1101 VETERANS DR
Practice Address - Street 2:VA MEDICAL CENTER (116A4-LD)
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40502-2236
Practice Address - Country:US
Practice Address - Phone:859-281-3817
Practice Address - Fax:859-281-3919
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI926103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical