Provider Demographics
NPI:1508360777
Name:BROADNAX, LISA (MED)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BROADNAX
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:BROADNAX-JACKSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 770
Mailing Address - Street 2:
Mailing Address - City:ZACHARY
Mailing Address - State:LA
Mailing Address - Zip Code:70791-0770
Mailing Address - Country:US
Mailing Address - Phone:225-306-2000
Mailing Address - Fax:225-658-1282
Practice Address - Street 1:6351 MAIN ST
Practice Address - Street 2:
Practice Address - City:ZACHARY
Practice Address - State:LA
Practice Address - Zip Code:70791-4038
Practice Address - Country:US
Practice Address - Phone:225-306-2000
Practice Address - Fax:225-658-1282
Is Sole Proprietor?:No
Enumeration Date:2018-03-21
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)