Provider Demographics
NPI:1316009624
Name:ROUSSEAU, DJENANE (RPH)
Entity Type:Individual
Prefix:MRS
First Name:DJENANE
Middle Name:
Last Name:ROUSSEAU
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19322
Mailing Address - Street 2:4140 HOLLYWOOD
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71109
Mailing Address - Country:US
Mailing Address - Phone:318-632-0325
Mailing Address - Fax:318-621-0169
Practice Address - Street 1:4140 HOLLYWOOD
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71109
Practice Address - Country:US
Practice Address - Phone:318-632-0325
Practice Address - Fax:318-621-0169
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA13699183500000X
LA28471R183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1925215OtherNABP
LA1261408Medicaid