Healthcare Provider Details

I. General information

NPI: 1235863556
Provider Name (Legal Business Name): JORDAN LETHOMMIUS PERRY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2022
Last Update Date: 09/13/2023
Certification Date: 09/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

318 W LOUISIANA AVE LOT 8
RUSTON LA
71270-9304
US

IV. Provider business mailing address

318 W LOUISIANA AVE LOT 8
RUSTON LA
71270-9304
US

V. Phone/Fax

Practice location:
  • Phone: 318-840-9287
  • Fax:
Mailing address:
  • Phone: 318-840-9287
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPLC8804
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: