Provider Demographics
NPI:1508282153
Name:MCCOY, JORDAN (MS, RD, RDN, CDCES)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:MCCOY
Suffix:
Gender:F
Credentials:MS, RD, RDN, CDCES
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 542
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:WY
Mailing Address - Zip Code:82836-0542
Mailing Address - Country:US
Mailing Address - Phone:307-752-7280
Mailing Address - Fax:
Practice Address - Street 1:618 HEATHER LANE
Practice Address - Street 2:
Practice Address - City:RANCHESTER
Practice Address - State:WY
Practice Address - Zip Code:82839
Practice Address - Country:US
Practice Address - Phone:307-752-7280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-06
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY158133V00000X, 133V00000X
MTMED-NUTR-LIC-52027133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered