Provider Demographics
NPI:1164869384
Name:MANDEL, JORDANA SAGE
Entity Type:Individual
Prefix:MRS
First Name:JORDANA
Middle Name:SAGE
Last Name:MANDEL
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:JORDAN
Other - Middle Name:SAGE
Other - Last Name:MANDEL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RD,CDE
Mailing Address - Street 1:560 NORTHERN BLVD
Mailing Address - Street 2:SUITE 207
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-5118
Mailing Address - Country:US
Mailing Address - Phone:516-466-6165
Mailing Address - Fax:
Practice Address - Street 1:560 NORTHERN BLVD
Practice Address - Street 2:SUITE207
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-5118
Practice Address - Country:US
Practice Address - Phone:516-466-6165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-29
Last Update Date:2013-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1002300133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered