Provider Demographics
NPI:1669726261
Name:BROYLES, JESSICA
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:
Last Name:BROYLES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1355 TUSCULUM BLVD
Mailing Address - Street 2:
Mailing Address - City:GREENEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37745-4249
Mailing Address - Country:US
Mailing Address - Phone:423-636-1344
Mailing Address - Fax:423-636-8951
Practice Address - Street 1:1355 TUSCULUM BLVD
Practice Address - Street 2:
Practice Address - City:GREENEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37745-4249
Practice Address - Country:US
Practice Address - Phone:423-636-1344
Practice Address - Fax:423-636-8951
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-04
Last Update Date:2012-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000029427183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist