Provider Demographics
NPI:1801294079
Name:BROTSKY, JENNIFER T (PSYD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:T
Last Name:BROTSKY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 WESTERN AVE
Mailing Address - Street 2:SUITE 3 #278
Mailing Address - City:AUGUSTA
Mailing Address - State:ME
Mailing Address - Zip Code:04330-6338
Mailing Address - Country:US
Mailing Address - Phone:207-449-3995
Mailing Address - Fax:
Practice Address - Street 1:18 BELVEDERE RD
Practice Address - Street 2:STE 302
Practice Address - City:DAMARISCOTTA
Practice Address - State:ME
Practice Address - Zip Code:04543-4645
Practice Address - Country:US
Practice Address - Phone:207-449-3995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-19
Last Update Date:2014-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS1435103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist