Healthcare Provider Details

I. General information

NPI: 1902298318
Provider Name (Legal Business Name): JORDAN SHERADEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2015
Last Update Date: 02/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 E LAKE SHORE DR
DECATUR IL
62521-3810
US

IV. Provider business mailing address

1800 E LAKE SHORE DR
DECATUR IL
62521-3810
US

V. Phone/Fax

Practice location:
  • Phone: 217-464-5241
  • Fax: 217-464-1647
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164.005628
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: