Provider Demographics
NPI:1184397192
Name:WARREN, JORDAN MARK
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:MARK
Last Name:WARREN
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 1:1125 HIGHWAY 80
Mailing Address - Street 2:
Mailing Address - City:HAUGHTON
Mailing Address - State:LA
Mailing Address - Zip Code:71037-9430
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1125 HIGHWAY 80
Practice Address - Street 2:
Practice Address - City:HAUGHTON
Practice Address - State:LA
Practice Address - Zip Code:71037-9430
Practice Address - Country:US
Practice Address - Phone:318-949-8476
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-26
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPST.0249641835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist