Provider Demographics
NPI:1639783822
Name:DOUGLAS, MARY GRACE JORDAN (PT)
Entity Type:Individual
Prefix:MRS
First Name:MARY GRACE
Middle Name:JORDAN
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:358 PRINCETON CIR
Mailing Address - Street 2:
Mailing Address - City:BELLE CHASSE
Mailing Address - State:LA
Mailing Address - Zip Code:70037-1311
Mailing Address - Country:US
Mailing Address - Phone:256-527-1177
Mailing Address - Fax:
Practice Address - Street 1:8397 HIGHWAY 23 STE 101
Practice Address - Street 2:
Practice Address - City:BELLE CHASSE
Practice Address - State:LA
Practice Address - Zip Code:70037-2609
Practice Address - Country:US
Practice Address - Phone:504-398-2004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-03
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA10836F225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA14961836OtherCAQH