Provider Demographics
NPI:1720288921
Name:BROUSSEAU, JOANNE LYNN (OT)
Entity type:Individual
Prefix:MS
First Name:JOANNE
Middle Name:LYNN
Last Name:BROUSSEAU
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 6TH AVE S APT E
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-6664
Mailing Address - Country:US
Mailing Address - Phone:904-449-0867
Mailing Address - Fax:
Practice Address - Street 1:221 6TH AVE S APT E
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32250-6664
Practice Address - Country:US
Practice Address - Phone:904-449-0867
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-25
Last Update Date:2013-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT0002801282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access