Provider Demographics
NPI:1801549373
Name:WALLEK, JORDAN (BCABA)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:WALLEK
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3253 SCHULER DRIVE
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71112-5129
Mailing Address - Country:US
Mailing Address - Phone:708-821-6255
Mailing Address - Fax:
Practice Address - Street 1:10450 ELLEBRE ROAD
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106
Practice Address - Country:US
Practice Address - Phone:318-797-8500
Practice Address - Fax:318-629-2735
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-03
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAC-058106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst