Provider Demographics
NPI:1558794065
Name:BROUSSARD, JESSIE M (LOTR)
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:M
Last Name:BROUSSARD
Suffix:
Gender:F
Credentials:LOTR
Other - Prefix:
Other - First Name:JESSIE
Other - Middle Name:
Other - Last Name:MECHE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LOTR
Mailing Address - Street 1:1322 ELTON RD
Mailing Address - Street 2:SUITE I
Mailing Address - City:JENNINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70546-4100
Mailing Address - Country:US
Mailing Address - Phone:337-824-5488
Mailing Address - Fax:
Practice Address - Street 1:1322 ELTON RD
Practice Address - Street 2:SUITE I
Practice Address - City:JENNINGS
Practice Address - State:LA
Practice Address - Zip Code:70546-4100
Practice Address - Country:US
Practice Address - Phone:337-824-5488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-20
Last Update Date:2013-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA200283225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist