1164790937 NPI number — JESSICA LA GRECO BROUSSE A.P.R.N., F.N.P.-C.

Table of content: JESSICA LA GRECO BROUSSE A.P.R.N., F.N.P.-C. (NPI 1164790937)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164790937 NPI number — JESSICA LA GRECO BROUSSE A.P.R.N., F.N.P.-C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROUSSE
Provider First Name:
JESSICA
Provider Middle Name:
LA GRECO
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
A.P.R.N., F.N.P.-C.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164790937
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/09/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5959 S SHERWOOD FOREST BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BATON ROUGE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70816-6038
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
225-526-0001
Provider Business Mailing Address Fax Number:
225-765-9196

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1520 GAUSE BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SLIDELL
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70458-2208
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
985-646-0945
Provider Business Practice Location Address Fax Number:
985-643-8510
Provider Enumeration Date:
12/08/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  AP06669 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1819417 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: P01030618 . This is a "RAILROAD MEDICARE PTAN" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".




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