Healthcare Provider Details

I. General information

NPI: 1073613709
Provider Name (Legal Business Name): SUSAN A JORDAN REGISTERED DIETITION
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2006
Last Update Date: 04/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 SOUTH 7650 EAST
CROW AGENCY MT
59022-0022
US

IV. Provider business mailing address

PO BOX 108
HARDIN MT
59034-0108
US

V. Phone/Fax

Practice location:
  • Phone: 406-638-3553
  • Fax: 406-638-3553
Mailing address:
  • Phone: 406-638-3553
  • Fax: 406-638-3569

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDT06018
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: