Provider Demographics
NPI:1487926671
Name:JORDAN, TRACY MINCHEW (FNP)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:MINCHEW
Last Name:JORDAN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2104 LOOP RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:WINNSBORO
Mailing Address - State:LA
Mailing Address - Zip Code:71295-3338
Mailing Address - Country:US
Mailing Address - Phone:318-435-4571
Mailing Address - Fax:318-435-7458
Practice Address - Street 1:2104 LOOP RD
Practice Address - Street 2:SUITE C
Practice Address - City:WINNSBORO
Practice Address - State:LA
Practice Address - Zip Code:71295-3338
Practice Address - Country:US
Practice Address - Phone:318-435-4571
Practice Address - Fax:318-435-7458
Is Sole Proprietor?:No
Enumeration Date:2012-02-02
Last Update Date:2012-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAPO6744363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner