MEDICARE: ANDREW JORDAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1366871477
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREW JORDAN

Provider Business Mailing Address
First Line	:	PO BOX 1281
Second Line	:	LAKESHORE DR., SUITE 618
City	:	LAKE CHARLES
State	:	LA
Zip	:	70602-1281
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1011 LAKE SHORE DR STE 618
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70601-9419
Country	:	US
Telephone Number	:	337-564-5394
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/08/2013
Last Update Date	:	11/08/2013

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