Provider Demographics
NPI:1841802717
Name:BROMAN, JENNA (OT)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:BROMAN
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:JENNA
Other - Middle Name:
Other - Last Name:SOBOCINSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:235 WEALTHY ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-5247
Mailing Address - Country:US
Mailing Address - Phone:616-840-7135
Mailing Address - Fax:616-840-9690
Practice Address - Street 1:1550 3 MILE RD NW STE C
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49544-8251
Practice Address - Country:US
Practice Address - Phone:616-840-8807
Practice Address - Fax:616-840-9684
Is Sole Proprietor?:No
Enumeration Date:2020-08-20
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MI5201013276225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician