Provider Demographics
NPI:1932616059
Name:JORDAN, MELISSA (RN)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:JORDAN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 918
Mailing Address - Street 2:
Mailing Address - City:DOYLINE
Mailing Address - State:LA
Mailing Address - Zip Code:71023-0918
Mailing Address - Country:US
Mailing Address - Phone:318-626-5597
Mailing Address - Fax:318-626-5691
Practice Address - Street 1:1543 GRIMMETT DR
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71107
Practice Address - Country:US
Practice Address - Phone:318-626-5597
Practice Address - Fax:318-626-5691
Is Sole Proprietor?:No
Enumeration Date:2018-01-10
Last Update Date:2018-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN032030163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)