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General NPI Number Information
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NPI Number | 1649311549
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Entity Type | Individual
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Provider Name | JAQUITA GWYNN JORDAN M.A., L.P.C.
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Gender | Female
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Dates
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Enumeration Date | 02/12/2007
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Last Update Date | 08/04/2011
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Provider Practice Location Address
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Address Line | 300 S 4TH ST
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City | LEESVILLE
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State | LA
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Zip | 71446-4318
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Country | US
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Telephone | 337-424-7406
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 431
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City | NEW LLANO
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State | LA
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Zip | 71461-0431
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Country | US
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Telephone | 337-424-7406
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 3044
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License Number State | LA
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