Provider Demographics
NPI:1477184018
Name:BONTRAGER, JORDAN (RD LMNT)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:BONTRAGER
Suffix:
Gender:F
Credentials:RD LMNT
Other - Prefix:
Other - First Name:JORDAN
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD LMNT
Mailing Address - Street 1:8207 NORTHWOODS DR STE 100
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68505-2093
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6829 N 72ND ST STE 4500
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68122-1724
Practice Address - Country:US
Practice Address - Phone:402-717-1299
Practice Address - Fax:402-717-0770
Is Sole Proprietor?:No
Enumeration Date:2020-02-03
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA110956133N00000X
NE133V00000X
NE1470133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered