Healthcare Provider Details

I. General information

NPI: 1861794729
Provider Name (Legal Business Name): JESSICA BROUSSARD BAUDOIN PH.D., LMFT, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2010
Last Update Date: 11/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4540 AMBASSADOR CAFFERY PKWY BUILDING D, SUITE B-220
LAFAYETTE LA
70508-6928
US

IV. Provider business mailing address

3936 OLIAS RD
ERATH LA
70533-6351
US

V. Phone/Fax

Practice location:
  • Phone: 337-981-2180
  • Fax: 337-981-2391
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number1138
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number4042
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: