Provider Demographics
NPI:1134319544
Name:BROUSSARD, JESSICA FORD (OTR/L)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:FORD
Last Name:BROUSSARD
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7117 GLENDALE ST
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70003-3103
Mailing Address - Country:US
Mailing Address - Phone:504-343-4926
Mailing Address - Fax:
Practice Address - Street 1:1005 E 23RD ST
Practice Address - Street 2:SUITE 200
Practice Address - City:FREMONT
Practice Address - State:NE
Practice Address - Zip Code:68025-0800
Practice Address - Country:US
Practice Address - Phone:866-784-2329
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-01
Last Update Date:2007-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAZ11945172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist