Provider Demographics
NPI:1518556901
Name:STICKLEY, JORDAN (RD)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:STICKLEY
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3270 GORDON LANDIS RD
Mailing Address - Street 2:
Mailing Address - City:ARCANUM
Mailing Address - State:OH
Mailing Address - Zip Code:45304-9683
Mailing Address - Country:US
Mailing Address - Phone:937-417-8442
Mailing Address - Fax:
Practice Address - Street 1:325 N MAIN ST STE 200E
Practice Address - Street 2:
Practice Address - City:SPRINGBORO
Practice Address - State:OH
Practice Address - Zip Code:45066-8005
Practice Address - Country:US
Practice Address - Phone:937-371-3450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-11
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH08862133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered