Provider Demographics
NPI:1073084588
Name:SPIVAK, JORDAN PAIGE (RDN, LDN)
Entity Type:Individual
Prefix:MISS
First Name:JORDAN
Middle Name:PAIGE
Last Name:SPIVAK
Suffix:
Gender:F
Credentials:RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1504 DARIEN CLUB DR
Mailing Address - Street 2:
Mailing Address - City:DARIEN
Mailing Address - State:IL
Mailing Address - Zip Code:60561-3683
Mailing Address - Country:US
Mailing Address - Phone:630-615-9144
Mailing Address - Fax:
Practice Address - Street 1:710 N FAIRBANKS CT STE 7-121
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-3013
Practice Address - Country:US
Practice Address - Phone:312-926-7437
Practice Address - Fax:312-926-4346
Is Sole Proprietor?:No
Enumeration Date:2018-12-10
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.007548133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered