Provider Demographics
NPI:1417083320
Name:BRAVO, JACQUELINE (PT)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:
Last Name:BRAVO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 MARBLE CREEK CV
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-1710
Mailing Address - Country:US
Mailing Address - Phone:337-406-0712
Mailing Address - Fax:337-406-0715
Practice Address - Street 1:100 WILLIAM O STUTES ST
Practice Address - Street 2:SUITE A
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70506-7211
Practice Address - Country:US
Practice Address - Phone:337-406-0712
Practice Address - Fax:337-406-0715
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA00974F225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4B856C960Medicare ID - Type Unspecified