Provider Demographics
NPI:1417432410
Name:BROUHARD, JACOB NATHANIEL
Entity Type:Individual
Prefix:MR
First Name:JACOB
Middle Name:NATHANIEL
Last Name:BROUHARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:681 MAIN STREET
Mailing Address - Street 2:SUITE 112
Mailing Address - City:PLACERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95667
Mailing Address - Country:US
Mailing Address - Phone:530-622-4880
Mailing Address - Fax:530-622-2360
Practice Address - Street 1:681 MAIN STREET
Practice Address - Street 2:SUITE 112
Practice Address - City:PLACERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95667
Practice Address - Country:US
Practice Address - Phone:530-622-4880
Practice Address - Fax:530-622-2360
Is Sole Proprietor?:No
Enumeration Date:2018-09-26
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COHA8392237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter