Provider Demographics
NPI:1366508046
Name:BROADDUS, JONELLE S (DPT)
Entity type:Individual
Prefix:
First Name:JONELLE
Middle Name:S
Last Name:BROADDUS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8466 TRIONE CIR
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CA
Mailing Address - Zip Code:95492-7704
Mailing Address - Country:US
Mailing Address - Phone:808-256-9522
Mailing Address - Fax:
Practice Address - Street 1:8466 TRIONE CIR
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:CA
Practice Address - Zip Code:95492-7704
Practice Address - Country:US
Practice Address - Phone:808-256-9522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2024-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33360225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist