MEDICARE: JORDAN ANNE HOSTETLER

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	121085	MT
2	133V00000X	Registered Dietitian	L005275	NC

General Provider Information

NPI Number	:	1659029122
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JORDAN ANNE HOSTETLER

Provider Business Mailing Address
First Line	:	30 2ND ST E STE B20
Second Line	:
City	:	KALISPELL
State	:	MT
Zip	:	59901-4563
Country	:	US
Telephone Number	:	406-407-9703
Fax Number	:

Provider Business Practice Location Address
First Line	:	30 2ND ST E STE B20
Second Line	:
City	:	KALISPELL
State	:	MT
Zip	:	59901-4563
Country	:	US
Telephone Number	:	406-407-9703
Fax Number	:

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

Provider Enumeration Date	:	03/14/2022
Last Update Date	:	05/30/2024

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