Provider Demographics
NPI:1376274340
Name:BROUSSARD, JENCY MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:JENCY
Middle Name:MARIE
Last Name:BROUSSARD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 SOMMERSET DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70506-5714
Mailing Address - Country:US
Mailing Address - Phone:337-852-1069
Mailing Address - Fax:
Practice Address - Street 1:1211 COOLIDGE STREET
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503
Practice Address - Country:US
Practice Address - Phone:337-232-6697
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-21
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty