MEDICARE: KELLY LOUISE BROUSSARD-JENKINS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	MA00025337	HI
2	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1831345610
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY LOUISE BROUSSARD-JENKINS

Provider Business Mailing Address
First Line	:	449 E SAINT PETER ST
Second Line	:
City	:	NEW IBERIA
State	:	LA
Zip	:	70560-3752
Country	:	US
Telephone Number	:	337-321-9204
Fax Number	:	337-321-9210

Provider Business Practice Location Address
First Line	:	449 E SAINT PETER ST
Second Line	:
City	:	NEW IBERIA
State	:	LA
Zip	:	70560-3752
Country	:	US
Telephone Number	:	337-321-9204
Fax Number	:	337-321-9210

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/13/2008
Last Update Date	:	05/27/2026

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