=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417219932
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAURA JANE JORDAN LPC, LMFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/11/2012
-----------------------------------------------------
Last Update Date | 12/12/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1100 NASA PKWY SUITE 110
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77058-3325
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-317-7237
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 125 RUSTIC COLONY LN
-----------------------------------------------------
City | DICKINSON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77539-4899
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-317-7237
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 66853
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------