Healthcare Provider Details

I. General information

NPI: 1063008712
Provider Name (Legal Business Name): TERRY GLEN JORDAN MS, LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2020
Last Update Date: 07/05/2023
Certification Date: 07/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 LAKE ST STE B
LAKE PROVIDENCE LA
71254-2550
US

IV. Provider business mailing address

PO BOX 1307
OAK GROVE LA
71263-1307
US

V. Phone/Fax

Practice location:
  • Phone: 318-552-5016
  • Fax:
Mailing address:
  • Phone: 318-680-4683
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number8116
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number8116
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: