Healthcare Provider Details

I. General information

NPI: 1962745364
Provider Name (Legal Business Name): JESSICA RACHELLE BROOM OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2013
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14517 MEADOWLAND CIR
NEWARK TX
76071-9103
US

IV. Provider business mailing address

14517 MEADOWLAND CIR
NEWARK TX
76071-9103
US

V. Phone/Fax

Practice location:
  • Phone: 817-381-8272
  • Fax:
Mailing address:
  • Phone: 817-381-8272
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number119420
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: