=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194295634
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RENEE S JORDAN MASTERS IN EDUCATION
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/27/2018
-----------------------------------------------------
Last Update Date | 08/22/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2110 OAK PARK BLVD
-----------------------------------------------------
City | LAKE CHARLES
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70601-7864
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 337-475-0324
-----------------------------------------------------
Fax | 337-475-8917
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5415 MATTIE REEVES RD
-----------------------------------------------------
City | LAKE CHARLES
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70611-5719
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 337-540-7098
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 246ZA2600X
-----------------------------------------------------
Taxonomy Name | Medical Art Specialist/Technologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------