Provider Demographics
NPI:1942383682
Name:BROERING, JACQUELYN (PT)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
Last Name:BROERING
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:COLDWATER
Mailing Address - State:OH
Mailing Address - Zip Code:45828-1703
Mailing Address - Country:US
Mailing Address - Phone:419-763-1464
Mailing Address - Fax:
Practice Address - Street 1:216 W MAIN ST
Practice Address - Street 2:
Practice Address - City:COLDWATER
Practice Address - State:OH
Practice Address - Zip Code:45828-1703
Practice Address - Country:US
Practice Address - Phone:419-763-1464
Practice Address - Fax:419-763-1482
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH11545225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist