=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578377529
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JORDYN MANNING MSN, APRN, PMHNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/01/2025
-----------------------------------------------------
Last Update Date | 02/01/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4830 LINE AVE
-----------------------------------------------------
City | SHREVEPORT
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71106-1530
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-490-8744
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1014 FAYETTEVILLE RD
-----------------------------------------------------
City | VAN BUREN
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72956-3427
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-490-8744
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 214635
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------