Provider Demographics
NPI:1285159871
Name:BROUSSARD, JANESSA MARIE
Entity type:Individual
Prefix:
First Name:JANESSA
Middle Name:MARIE
Last Name:BROUSSARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:470 CASTRO ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94114-2482
Mailing Address - Country:US
Mailing Address - Phone:415-581-1600
Mailing Address - Fax:415-581-1610
Practice Address - Street 1:470 CASTRO ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94114-2482
Practice Address - Country:US
Practice Address - Phone:415-581-1600
Practice Address - Fax:415-581-1610
Is Sole Proprietor?:No
Enumeration Date:2017-08-04
Last Update Date:2018-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95007103363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95007103OtherNP LICENSE