Provider Demographics
NPI:1639109952
Name:JORDAN'S CROSSING HOSPICE, LLC
Entity Type:Organization
Organization Name:JORDAN'S CROSSING HOSPICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR/ADMIN/CO OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BECKI
Authorized Official - Middle Name:D
Authorized Official - Last Name:PRUDHOME
Authorized Official - Suffix:
Authorized Official - Credentials:RN, CHPN, CHA
Authorized Official - Phone:318-631-6789
Mailing Address - Street 1:624 TRAVIS ST
Mailing Address - Street 2:SUITE 700
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-3013
Mailing Address - Country:US
Mailing Address - Phone:318-631-6789
Mailing Address - Fax:318-631-6727
Practice Address - Street 1:624 TRAVIS ST
Practice Address - Street 2:SUITE 700
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-3013
Practice Address - Country:US
Practice Address - Phone:318-631-6789
Practice Address - Fax:318-631-6727
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-03
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA176251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1584215Medicaid
LA1584215Medicaid