Provider Demographics
NPI:1134717762
Name:BROSI, JENNY
Entity type:Individual
Prefix:
First Name:JENNY
Middle Name:
Last Name:BROSI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 ATWATER ST N
Mailing Address - Street 2:
Mailing Address - City:MONMOUTH
Mailing Address - State:OR
Mailing Address - Zip Code:97361-1801
Mailing Address - Country:US
Mailing Address - Phone:503-606-3288
Mailing Address - Fax:
Practice Address - Street 1:180 ATWATER ST N
Practice Address - Street 2:
Practice Address - City:MONMOUTH
Practice Address - State:OR
Practice Address - Zip Code:97361-1801
Practice Address - Country:US
Practice Address - Phone:503-606-3287
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-08
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1021064363LC0200X
OR10013536363LF0000X
TX1020164363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2E7434Medicaid