Healthcare Provider Details

I. General information

NPI: 1316842644
Provider Name (Legal Business Name): JORDYN BROOKE STONE RD
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/08/2026
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 PACIFIC ST APT 356
STAMFORD CT
06902-7369
US

IV. Provider business mailing address

850 PACIFIC ST APT 356
STAMFORD CT
06902-7369
US

V. Phone/Fax

Practice location:
  • Phone: 516-426-6278
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number086291121
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: