Healthcare Provider Details

I. General information

NPI: 1720081193
Provider Name (Legal Business Name): JACK L. BREAUX JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2005
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8080 BLUEBONNET BLVD STE 2222
BATON ROUGE LA
70810-7828
US

IV. Provider business mailing address

604 N ACADIA RD STE 101
THIBODAUX LA
70301-4897
US

V. Phone/Fax

Practice location:
  • Phone: 225-769-2222
  • Fax: 225-757-8061
Mailing address:
  • Phone: 985-446-5079
  • Fax: 985-447-2497

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number013762
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number013762
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: