Provider Demographics
NPI:1083806640
Name:JORDAN, KRISTA M (RD)
Entity Type:Individual
Prefix:MRS
First Name:KRISTA
Middle Name:M
Last Name:JORDAN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:MISS
Other - First Name:KRISTA
Other - Middle Name:M
Other - Last Name:KIRSCHBAUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:5955 ZEAMER AVENUE
Mailing Address - Street 2:3RD MDG/WIC OFFICE
Mailing Address - City:ELMENDORF AFB
Mailing Address - State:AK
Mailing Address - Zip Code:99506
Mailing Address - Country:US
Mailing Address - Phone:907-580-3205
Mailing Address - Fax:
Practice Address - Street 1:5955 ZEAMER AVENUE
Practice Address - Street 2:3RD MDG/WIC OFFICE
Practice Address - City:ELMENDORF AFB
Practice Address - State:AK
Practice Address - Zip Code:99506
Practice Address - Country:US
Practice Address - Phone:907-580-3205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-16
Last Update Date:2007-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK130133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered