Healthcare Provider Details

I. General information

NPI: 1811779697
Provider Name (Legal Business Name): JADA ROUSSEAU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2023
Last Update Date: 01/15/2025
Certification Date: 01/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

379 6TH AVE W
BRADENTON FL
34205-8820
US

IV. Provider business mailing address

3300 17TH ST
SARASOTA FL
34235-8904
US

V. Phone/Fax

Practice location:
  • Phone: 941-782-4150
  • Fax: 941-782-4301
Mailing address:
  • Phone: 941-259-3716
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: