Healthcare Provider Details

I. General information

NPI: 1366785750
Provider Name (Legal Business Name): JESSICA LYN LAORDEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2013
Last Update Date: 07/02/2025
Certification Date: 07/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1724 W PLYMOUTH ST
BREMEN IN
46506-1940
US

IV. Provider business mailing address

1500 S MAIN ST
FORT WORTH TX
76104-4917
US

V. Phone/Fax

Practice location:
  • Phone: 574-546-3045
  • Fax: 574-546-2716
Mailing address:
  • Phone: 817-702-1215
  • Fax: 817-702-1697

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberBP10049934
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301114134
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: