Provider Demographics
NPI:1659871796
Name:BROUSSARD, JODY MACK
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:MACK
Last Name:BROUSSARD
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 1:494 OTTO FRANKLIN RD
Mailing Address - Street 2:
Mailing Address - City:DERIDDER
Mailing Address - State:LA
Mailing Address - Zip Code:70634-6404
Mailing Address - Country:US
Mailing Address - Phone:337-396-1312
Mailing Address - Fax:337-462-0283
Practice Address - Street 1:494 OTTO FRANKLIN RD
Practice Address - Street 2:
Practice Address - City:DERIDDER
Practice Address - State:LA
Practice Address - Zip Code:70634-6404
Practice Address - Country:US
Practice Address - Phone:337-396-1312
Practice Address - Fax:337-462-0283
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-15
Last Update Date:2018-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA005855942172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver