Provider Demographics
NPI:1174184063
Name:HAMILTON, JORDAN LORENZO
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:LORENZO
Last Name:HAMILTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:254 MARIGOLD ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT AIRY
Mailing Address - State:LA
Mailing Address - Zip Code:70076-2119
Mailing Address - Country:US
Mailing Address - Phone:985-817-3432
Mailing Address - Fax:
Practice Address - Street 1:254 MARIGOLD ST
Practice Address - Street 2:
Practice Address - City:MOUNT AIRY
Practice Address - State:LA
Practice Address - Zip Code:70076-2119
Practice Address - Country:US
Practice Address - Phone:985-817-3432
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-22
Last Update Date:2019-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator