Provider Demographics
NPI:1801096920
Name:ROUSSEAU, JEANNETTE ELIZABETH (LDN RD CDE)
Entity type:Individual
Prefix:MS
First Name:JEANNETTE
Middle Name:ELIZABETH
Last Name:ROUSSEAU
Suffix:
Gender:F
Credentials:LDN RD CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:298 CINDY LOU PLACE
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70448
Mailing Address - Country:US
Mailing Address - Phone:985-626-0128
Mailing Address - Fax:
Practice Address - Street 1:1202 S TYLER STREET
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433
Practice Address - Country:US
Practice Address - Phone:985-898-4000
Practice Address - Fax:985-898-3778
Is Sole Proprietor?:No
Enumeration Date:2007-07-18
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA348133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
4C208Medicare UPIN