Provider Demographics
NPI:1255937884
Name:BROADNAX, JAYTAVIA
Entity type:Individual
Prefix:
First Name:JAYTAVIA
Middle Name:
Last Name:BROADNAX
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 1:10044 PALERMO CIR APT 203
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33619-5073
Mailing Address - Country:US
Mailing Address - Phone:630-200-4823
Mailing Address - Fax:
Practice Address - Street 1:2311 ALT 19
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34683-2631
Practice Address - Country:US
Practice Address - Phone:630-200-4823
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-09
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1306862511Medicaid