Healthcare Provider Details

I. General information

NPI: 1861991390
Provider Name (Legal Business Name): LAQUEEN JORDON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/11/2018
Last Update Date: 02/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1532 FRIENZA AVE
SACRAMENTO CA
95815-2735
US

IV. Provider business mailing address

1532 FRIENZA AVE
SACRAMENTO CA
95815-2735
US

V. Phone/Fax

Practice location:
  • Phone: 916-242-5339
  • Fax:
Mailing address:
  • Phone: 916-242-5339
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code146D00000X
TaxonomyPersonal Emergency Response Attendant
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License Number545-7353092
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code175M00000X
TaxonomyLay Midwife
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: