Provider Demographics
NPI:1881059038
Name:BRODERICK, JESSICA (MSED, CCC-SLP, ATP)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BRODERICK
Suffix:
Gender:F
Credentials:MSED, CCC-SLP, ATP
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:GRASMICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1202 LARKSPUR DR
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBLUFF
Mailing Address - State:NE
Mailing Address - Zip Code:69361-4513
Mailing Address - Country:US
Mailing Address - Phone:308-641-5615
Mailing Address - Fax:
Practice Address - Street 1:2027 10TH ST
Practice Address - Street 2:
Practice Address - City:GERING
Practice Address - State:NE
Practice Address - Zip Code:69341-2417
Practice Address - Country:US
Practice Address - Phone:308-641-5615
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-15
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1745235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist