Healthcare Provider Details

I. General information

NPI: 1518556901
Provider Name (Legal Business Name): JORDAN FLORY RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JORDAN STICKLEY RD

II. Dates (important events)

Enumeration Date: 01/11/2021
Last Update Date: 04/30/2026
Certification Date: 04/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 N MAIN ST STE 200E
SPRINGBORO OH
45066-8005
US

IV. Provider business mailing address

3270 GORDON LANDIS RD
ARCANUM OH
45304-9683
US

V. Phone/Fax

Practice location:
  • Phone: 937-371-3450
  • Fax:
Mailing address:
  • Phone: 937-417-8442
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number08862
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: