Healthcare Provider Details

I. General information

NPI: 1972759777
Provider Name (Legal Business Name): JORDAN MARCUS FORSTHOFF NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2008
Last Update Date: 03/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

435 HEYMANN BLVD
LAFAYETTE LA
70503-2616
US

IV. Provider business mailing address

435 HEYMANN BLVD
LAFAYETTE LA
70503-2616
US

V. Phone/Fax

Practice location:
  • Phone: 337-234-3344
  • Fax: 337-234-3352
Mailing address:
  • Phone: 337-234-3344
  • Fax: 337-234-3352

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberAP05418
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: