Provider Demographics
NPI:1255852851
Name:BROUSSARD, JENNIFER ALISON (NP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ALISON
Last Name:BROUSSARD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:A
Other - Last Name:MATHIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3400 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-2513
Mailing Address - Country:US
Mailing Address - Phone:478-474-5600
Mailing Address - Fax:478-471-6769
Practice Address - Street 1:3400 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-2513
Practice Address - Country:US
Practice Address - Phone:478-474-5600
Practice Address - Fax:478-471-6769
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-05
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN204586363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner