Healthcare Provider Details

I. General information

NPI: 1972215937
Provider Name (Legal Business Name): ONNIE BISHOP JORDAN RDN, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2022
Last Update Date: 12/21/2022
Certification Date: 12/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 11TH AVE NE
ST PETERSBURG FL
33701-1823
US

IV. Provider business mailing address

145 11TH AVE NE
ST PETERSBURG FL
33701-1823
US

V. Phone/Fax

Practice location:
  • Phone: 678-478-1696
  • Fax:
Mailing address:
  • Phone: 678-478-1696
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License NumberND7278
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberND7278
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: