MEDICARE: DR. JACK L. BREAUX JR. M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207YX0007X	Plastic Surgery within the Head & Neck (Otolaryngology) Physician	013762	LA
2	207Y00000X	Otolaryngology Physician	013762	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1720081193
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACK L. BREAUX JR. M.D.

Provider Business Mailing Address
First Line	:	604 N ACADIA RD STE 101
Second Line	:
City	:	THIBODAUX
State	:	LA
Zip	:	70301-4897
Country	:	US
Telephone Number	:	985-446-5079
Fax Number	:	985-447-2497

Provider Business Practice Location Address
First Line	:	8080 BLUEBONNET BLVD
Second Line	:	STE 2222
City	:	BATON ROUGE
State	:	LA
Zip	:	70810-7828
Country	:	US
Telephone Number	:	225-769-2222
Fax Number	:	225-757-8061

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/31/2005
Last Update Date	:	06/25/2026

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Directions to “ DR. JACK L. BREAUX JR. M.D.” Practice Location

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