Provider Demographics
NPI:1861991390
Name:JORDON, LAQUEEN
Entity type:Individual
Prefix:
First Name:LAQUEEN
Middle Name:
Last Name:JORDON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1532 FRIENZA AVE
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95815-2735
Mailing Address - Country:US
Mailing Address - Phone:916-242-5339
Mailing Address - Fax:
Practice Address - Street 1:1532 FRIENZA AVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95815-2735
Practice Address - Country:US
Practice Address - Phone:916-242-5339
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-11
Last Update Date:2018-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
146D00000X, 175M00000X, 133N00000X
TX545-7353092163WA2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
No146D00000XEmergency Medical Service ProvidersPersonal Emergency Response Attendant
No163WA2000XNursing Service ProvidersRegistered NurseAdministrator
No175M00000XOther Service ProvidersMidwife, Lay