Provider Demographics
NPI:1174808034
Name:BROSSMAN, JENNIFER (RBT-23-253709)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BROSSMAN
Suffix:
Gender:F
Credentials:RBT-23-253709
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 POINTE PARKWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73099-0600
Mailing Address - Country:US
Mailing Address - Phone:405-805-6403
Mailing Address - Fax:
Practice Address - Street 1:1222 W WESTCHESTER WAY
Practice Address - Street 2:
Practice Address - City:MUSTANG
Practice Address - State:OK
Practice Address - Zip Code:73064-2303
Practice Address - Country:US
Practice Address - Phone:405-816-1014
Practice Address - Fax:405-422-8249
Is Sole Proprietor?:No
Enumeration Date:2011-10-11
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
OKRBT-23-253709106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKRBT-23-253709Medicaid