Provider Demographics
NPI:1033554738
Name:JORDAN, MELISSA FETT
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:FETT
Last Name:JORDAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:DIANNE
Other - Last Name:FETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3100 FAIRFIELD AVE
Mailing Address - Street 2:UNIT 10A
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71104-4152
Mailing Address - Country:US
Mailing Address - Phone:318-201-3939
Mailing Address - Fax:
Practice Address - Street 1:3100 FAIRFIELD AVE
Practice Address - Street 2:UNIT 10A
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71104-4152
Practice Address - Country:US
Practice Address - Phone:318-201-3939
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-08
Last Update Date:2013-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA390200000207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology