Provider Demographics
NPI:1831811082
Name:BROADWAY, JAYLYN ALYSE (AMFT)
Entity type:Individual
Prefix:
First Name:JAYLYN
Middle Name:ALYSE
Last Name:BROADWAY
Suffix:
Gender:F
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 N PRAIRIE AVE STE 150
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90301-4503
Mailing Address - Country:US
Mailing Address - Phone:310-846-2064
Mailing Address - Fax:
Practice Address - Street 1:4760 SEPULVEDA BLVD
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90230-4820
Practice Address - Country:US
Practice Address - Phone:310-751-5438
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-14
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA134012106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist