Healthcare Provider Details

I. General information

NPI: 1588582035
Provider Name (Legal Business Name): JAMIE RYAN BROUSSARD II MSN, APRN, PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2026
Last Update Date: 07/11/2026
Certification Date: 07/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 FLAGG PL
LAFAYETTE LA
70508-7025
US

IV. Provider business mailing address

113 FLAGG PL
LAFAYETTE LA
70508-7025
US

V. Phone/Fax

Practice location:
  • Phone: 337-247-7282
  • Fax:
Mailing address:
  • Phone: 337-247-7282
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number208246
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: