Healthcare Provider Details

I. General information

NPI: 1245956531
Provider Name (Legal Business Name): JORDAN DAILEY HICKS MS, RDN, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2022
Last Update Date: 10/18/2022
Certification Date: 07/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL CENTER BLVD
WINSTON SALEM NC
27157-2797
US

IV. Provider business mailing address

5770 MIDSTREAM CIR
CLEMMONS NC
27012-9691
US

V. Phone/Fax

Practice location:
  • Phone: 336-713-4500
  • Fax:
Mailing address:
  • Phone: 770-712-5096
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: