Provider Demographics
NPI:1982211991
Name:BROADDUS, JENNIFER (LCSW-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BROADDUS
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11376 BARLEY FIELD WAY
Mailing Address - Street 2:
Mailing Address - City:MARRIOTTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21104-1339
Mailing Address - Country:US
Mailing Address - Phone:443-472-5791
Mailing Address - Fax:
Practice Address - Street 1:11376 BARLEY FIELD WAY
Practice Address - Street 2:
Practice Address - City:MARRIOTTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21104-1339
Practice Address - Country:US
Practice Address - Phone:443-472-5791
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-24
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD0583C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical