=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811817737
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA BRODIE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/20/2026
-----------------------------------------------------
Last Update Date | 07/20/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 103 E 8TH ST
-----------------------------------------------------
City | GEORGETOWN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78626-5801
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 737-888-4010
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 103 PINE BLUFF DR
-----------------------------------------------------
City | LA PORTE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77571-6623
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-526-1696
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 107579
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------