Provider Demographics
NPI:1457980104
Name:BROMM, JENNIFER ROSE
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ROSE
Last Name:BROMM
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 1:2960 S SANTINE RD
Mailing Address - Street 2:
Mailing Address - City:SAINT ANTHONY
Mailing Address - State:IN
Mailing Address - Zip Code:47575-9702
Mailing Address - Country:US
Mailing Address - Phone:812-827-1359
Mailing Address - Fax:
Practice Address - Street 1:4301 W MARKHAM ST # 518
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-7101
Practice Address - Country:US
Practice Address - Phone:501-526-7569
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-05
Last Update Date:2020-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program