Healthcare Provider Details

I. General information

NPI: 1134319544
Provider Name (Legal Business Name): JESSICA FORD BROUSSARD OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2007
Last Update Date: 08/01/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 E 23RD ST SUITE 200
FREMONT NE
68025-0800
US

IV. Provider business mailing address

7117 GLENDALE ST
METAIRIE LA
70003-3103
US

V. Phone/Fax

Practice location:
  • Phone: 866-784-2329
  • Fax:
Mailing address:
  • Phone: 504-343-4926
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172M00000X
TaxonomyMechanotherapist
License NumberZ11945
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: