MEDICARE: MRS. JORDAN LARSON RDN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	86290785	IL

General Provider Information

NPI Number	:	1568236248
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JORDAN LARSON RDN

Provider Business Mailing Address
First Line	:	720 W GORDON TER APT 22F
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-2263
Country	:	US
Telephone Number	:	847-508-7844
Fax Number	:

Provider Business Practice Location Address
First Line	:	720 W GORDON TER APT 22F
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-2263
Country	:	US
Telephone Number	:	847-508-7844
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/13/2023
Last Update Date	:	01/08/2024

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