Provider Demographics
NPI:1932561768
Name:BRODY, JENNIFER BUTTERFIELD (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:BUTTERFIELD
Last Name:BRODY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:JENNIFER
Other - Middle Name:CAROL
Other - Last Name:BUTTERFIELD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 417
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34995-0417
Mailing Address - Country:US
Mailing Address - Phone:772-223-2832
Mailing Address - Fax:772-223-5653
Practice Address - Street 1:1651 SE TIFFANY AVE
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-7564
Practice Address - Country:US
Practice Address - Phone:772-398-1800
Practice Address - Fax:770-398-1815
Is Sole Proprietor?:No
Enumeration Date:2016-03-22
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9108965363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLKHX57OtherFLORIDA BLUE
FL021744000Medicaid