Healthcare Provider Details

I. General information

NPI: 1801096920
Provider Name (Legal Business Name): JEANNETTE ELIZABETH ROUSSEAU LDN RD CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2007
Last Update Date: 07/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1202 S TYLER STREET
COVINGTON LA
70433
US

IV. Provider business mailing address

298 CINDY LOU PLACE
MANDEVILLE LA
70448
US

V. Phone/Fax

Practice location:
  • Phone: 985-898-4000
  • Fax: 985-898-3778
Mailing address:
  • Phone: 985-626-0128
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number348
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: