Provider Demographics
NPI:1538728225
Name:BRODERICK, JESSICA LYNN (DO)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:BRODERICK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:LYNN
Other - Last Name:BEVLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:707 HOLLYBROOK DR
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605-2410
Mailing Address - Country:US
Mailing Address - Phone:903-757-6042
Mailing Address - Fax:
Practice Address - Street 1:707 HOLLYBROOK DR
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-2410
Practice Address - Country:US
Practice Address - Phone:903-757-6042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-06
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXV2445208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery