Provider Demographics
NPI:1497580575
Name:BROUGHTON, JENNIFER (PSYS, NCSP)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:BROUGHTON
Suffix:
Gender:F
Credentials:PSYS, NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2813 GRANT LINE RD
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:IN
Mailing Address - Zip Code:47150-2457
Mailing Address - Country:US
Mailing Address - Phone:812-542-2168
Mailing Address - Fax:
Practice Address - Street 1:2813 GRANT LINE RD
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-2457
Practice Address - Country:US
Practice Address - Phone:812-542-2168
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-06
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10317374103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool