Provider Demographics
NPI:1720351273
Name:BROYLES, JENNIFER ROSE (LPC-S, CM2, PTA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ROSE
Last Name:BROYLES
Suffix:
Gender:F
Credentials:LPC-S, CM2, PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 BROADWAY
Mailing Address - Street 2:SUITE 1
Mailing Address - City:POTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74953
Mailing Address - Country:US
Mailing Address - Phone:918-649-0772
Mailing Address - Fax:
Practice Address - Street 1:900 BROADWAY
Practice Address - Street 2:SUITE 1
Practice Address - City:POTEAU
Practice Address - State:OK
Practice Address - Zip Code:74953
Practice Address - Country:US
Practice Address - Phone:918-649-0772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-14
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1896225200000X
OKSUPERVISION101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant