Provider Demographics
NPI:1073613709
Name:JORDAN, SUSAN A (REGISTERED DIETITION)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:A
Last Name:JORDAN
Suffix:
Gender:F
Credentials:REGISTERED DIETITION
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 108
Mailing Address - Street 2:
Mailing Address - City:HARDIN
Mailing Address - State:MT
Mailing Address - Zip Code:59034-0108
Mailing Address - Country:US
Mailing Address - Phone:406-638-3553
Mailing Address - Fax:406-638-3569
Practice Address - Street 1:1010 SOUTH
Practice Address - Street 2:7650 EAST
Practice Address - City:CROW AGENCY
Practice Address - State:MT
Practice Address - Zip Code:59022-0022
Practice Address - Country:US
Practice Address - Phone:406-638-3553
Practice Address - Fax:406-638-3553
Is Sole Proprietor?:No
Enumeration Date:2006-09-23
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT06018133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT2210068Medicaid
TXDT06018OtherTEXAS STATE BOARD