Individual
JENNIFER LAURA BROADT
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA
Contact information
Practice address
915 WISCONSIN AVE, TIETON, WA 98947-9802
(509) 673-0044
(509) 673-0054
Mailing address
501 S 5TH AVE, YAKIMA, WA 98902-3550
(509) 494-6700
(509) 573-6275
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
PA60703623
WA
363A00000X
Physician Assistant
—
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
354348001
—
TX
01
—
354348002
CSHCN MEDICAID
TX
01
—
47272ZSJC
MEDICARE
TX
01
—
8860NU
SOLO BCBS
TX
01
—
P01610841
RAILROAD MEDICARE
TX
Enumeration date
01/25/2016
Last updated
12/05/2016
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