Provider Demographics
NPI:1134739832
Name:BROUSSARD, JESSICA CLARE (MS, RDN)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:CLARE
Last Name:BROUSSARD
Suffix:
Gender:F
Credentials:MS, RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1297 INDIANA AVE
Mailing Address - Street 2:
Mailing Address - City:THORSBY
Mailing Address - State:AL
Mailing Address - Zip Code:35171-8149
Mailing Address - Country:US
Mailing Address - Phone:205-646-0431
Mailing Address - Fax:
Practice Address - Street 1:1297 INDIANA AVE
Practice Address - Street 2:
Practice Address - City:THORSBY
Practice Address - State:AL
Practice Address - Zip Code:35171-8149
Practice Address - Country:US
Practice Address - Phone:205-646-0431
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-06
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered