Provider Demographics
NPI:1326546870
Name:PARK, JORDAN MARIE (MS, RDN, CSSD, LDN)
Entity Type:Individual
Prefix:MISS
First Name:JORDAN
Middle Name:MARIE
Last Name:PARK
Suffix:
Gender:F
Credentials:MS, RDN, CSSD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4721 LOMA DE PLATA DR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79934-3580
Mailing Address - Country:US
Mailing Address - Phone:915-264-5797
Mailing Address - Fax:
Practice Address - Street 1:4721 LOMA DE PLATA DR
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79934-3580
Practice Address - Country:US
Practice Address - Phone:915-264-5797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-30
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86049646133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered