Healthcare Provider Details

I. General information

NPI: 1801423132
Provider Name (Legal Business Name): JORDAN HILL RD, CSSD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2020
Last Update Date: 09/06/2022
Certification Date: 09/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

785 S LAFAYETTE DR APT 265
LAFAYETTE CO
80026-3575
US

IV. Provider business mailing address

785 S LAFAYETTE DR APT 265
LAFAYETTE CO
80026-3575
US

V. Phone/Fax

Practice location:
  • Phone: 404-547-9576
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1501X
TaxonomySports Dietetics Nutrition Registered Dietitian
License Number86056727
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86056727
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: