Healthcare Provider Details

I. General information

NPI: 1194295634
Provider Name (Legal Business Name): RENEE S JORDAN MASTERS IN EDUCATION
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2018
Last Update Date: 08/22/2024
Certification Date: 08/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2110 OAK PARK BLVD
LAKE CHARLES LA
70601-7864
US

IV. Provider business mailing address

5415 MATTIE REEVES RD
LAKE CHARLES LA
70611-5719
US

V. Phone/Fax

Practice location:
  • Phone: 337-475-0324
  • Fax: 337-475-8917
Mailing address:
  • Phone: 337-540-7098
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246ZA2600X
TaxonomyMedical Art Specialist/Technologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: