Healthcare Provider Details

I. General information

NPI: 1649069089
Provider Name (Legal Business Name): JORDAN MICHAEL COLE CIT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2025
Last Update Date: 05/02/2025
Certification Date: 05/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 HOLIDAY BLVD STE 400
COVINGTON LA
70433-5282
US

IV. Provider business mailing address

201 HOLIDAY BLVD STE 400
COVINGTON LA
70433-5282
US

V. Phone/Fax

Practice location:
  • Phone: 504-677-8474
  • Fax: 985-273-3869
Mailing address:
  • Phone: 504-677-8474
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCIT-5453
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: