Provider Demographics
NPI:1801778337
Name:MCBROOM, JENTRY (PA)
Entity type:Individual
Prefix:
First Name:JENTRY
Middle Name:
Last Name:MCBROOM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JENTRY
Other - Middle Name:
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:902 E LINCOLN RD
Mailing Address - Street 2:
Mailing Address - City:IDABEL
Mailing Address - State:OK
Mailing Address - Zip Code:74745-7337
Mailing Address - Country:US
Mailing Address - Phone:580-286-2600
Mailing Address - Fax:
Practice Address - Street 1:902 E LINCOLN RD
Practice Address - Street 2:
Practice Address - City:IDABEL
Practice Address - State:OK
Practice Address - Zip Code:74745-7337
Practice Address - Country:US
Practice Address - Phone:580-286-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-24
Last Update Date:2025-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5486363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant