Provider Demographics
NPI:1053293092
Name:ROUSSELL, JACELYN JADE (PHARMD)
Entity type:Individual
Prefix:DR
First Name:JACELYN
Middle Name:JADE
Last Name:ROUSSELL
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:JACELYN
Other - Middle Name:JADE
Other - Last Name:LATHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:74640 TANTELA RANCH RD
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70435-7092
Mailing Address - Country:US
Mailing Address - Phone:601-916-0279
Mailing Address - Fax:
Practice Address - Street 1:235 FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:PICAYUNE
Practice Address - State:MS
Practice Address - Zip Code:39466-7514
Practice Address - Country:US
Practice Address - Phone:601-799-1063
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-22
Last Update Date:2025-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-102026183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist