Basic Information
| Provider Information | |||||||||
| NPI: | 1225620917 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JORDAN | ||||||||
| FirstName: | BETHANY | ||||||||
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| Credential: | PLMFT, PLPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1812 GLENMAR AVE STE C | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712014974 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3186547010 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1812 GLENMAR AVE STE C | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712014974 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3186547010 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/04/2021 | ||||||||
| LastUpdateDate: | 02/04/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | PLC8210 | LA | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.