Provider Demographics
NPI:1255615290
Name:BRASSEAUX, JACKIE LINN (LMT)
Entity type:Individual
Prefix:MRS
First Name:JACKIE
Middle Name:LINN
Last Name:BRASSEAUX
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1857 WOODDALE BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70706
Mailing Address - Country:US
Mailing Address - Phone:225-927-8160
Mailing Address - Fax:225-927-7751
Practice Address - Street 1:1857 WOODDALE BLVD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-1510
Practice Address - Country:US
Practice Address - Phone:225-927-8160
Practice Address - Fax:225-927-7751
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-10
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA4751-2225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist