Provider Demographics
NPI:1346572658
Name:BROUSSARD, JIA MAE-AIMEE (ASW)
Entity Type:Individual
Prefix:
First Name:JIA
Middle Name:MAE-AIMEE
Last Name:BROUSSARD
Suffix:
Gender:F
Credentials:ASW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 COLE ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94117-2800
Mailing Address - Country:US
Mailing Address - Phone:415-386-9398
Mailing Address - Fax:415-386-8212
Practice Address - Street 1:555 COLE ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94117-2800
Practice Address - Country:US
Practice Address - Phone:415-386-9398
Practice Address - Fax:415-386-8212
Is Sole Proprietor?:No
Enumeration Date:2010-02-11
Last Update Date:2016-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor