Provider Demographics
NPI:1104657303
Name:DAVIS, JORDAN WENDOLYN (MS, RDN, LDN)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:WENDOLYN
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MS, RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5215 ESSEN LN STE 200
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-3543
Mailing Address - Country:US
Mailing Address - Phone:225-767-0847
Mailing Address - Fax:885-767-1335
Practice Address - Street 1:15728 PAUL VEGA MD DR
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70403-1434
Practice Address - Country:US
Practice Address - Phone:985-542-5000
Practice Address - Fax:985-542-1138
Is Sole Proprietor?:No
Enumeration Date:2024-08-09
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSD-2466133V00000X
LA3408133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered