Healthcare Provider Details

I. General information

NPI: 1972184273
Provider Name (Legal Business Name): BRADLEY JAMES JORDAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2021
Last Update Date: 09/13/2024
Certification Date: 09/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5326 OAK ST
SAINT FRANCISVILLE LA
70775-4510
US

IV. Provider business mailing address

PO BOX 487
SAINT FRANCISVILLE LA
70775-0487
US

V. Phone/Fax

Practice location:
  • Phone: 225-635-5848
  • Fax: 225-635-9595
Mailing address:
  • Phone: 225-635-5848
  • Fax: 225-635-9595

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number340609
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: