Provider Demographics
NPI:1265987085
Name:BROADWAY, JENNIFER MARIE
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIE
Last Name:BROADWAY
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 1:11710 PLEASANT RIDGE TER
Mailing Address - Street 2:APT. 1406
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72223-2366
Mailing Address - Country:US
Mailing Address - Phone:870-378-4464
Mailing Address - Fax:
Practice Address - Street 1:17706 I 30
Practice Address - Street 2:SUITE 3
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72019-2907
Practice Address - Country:US
Practice Address - Phone:501-315-4414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-22
Last Update Date:2016-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROT-A1116224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant