Basic Information
Provider Information | |||||||||
NPI: | 1508360777 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BROADNAX | ||||||||
FirstName: | LISA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MED | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BROADNAX-JACKSON | ||||||||
OtherFirstName: | LISA | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 770 | ||||||||
Address2: |   | ||||||||
City: | ZACHARY | ||||||||
State: | LA | ||||||||
PostalCode: | 707910770 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2253062000 | ||||||||
FaxNumber: | 2256581282 | ||||||||
Practice Location | |||||||||
Address1: | 6351 MAIN ST | ||||||||
Address2: |   | ||||||||
City: | ZACHARY | ||||||||
State: | LA | ||||||||
PostalCode: | 707914038 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2253062000 | ||||||||
FaxNumber: | 2256581282 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/21/2018 | ||||||||
LastUpdateDate: | 03/21/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X |   |   | Y |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.