Provider Demographics
NPI:1588219745
Name:JUREK, JORDAN S (RD)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:S
Last Name:JUREK
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 1:18001 N 79TH AVE STE A12
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-8398
Mailing Address - Country:US
Mailing Address - Phone:623-399-6825
Mailing Address - Fax:623-505-3474
Practice Address - Street 1:3815 E BELL RD # 4250
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-2122
Practice Address - Country:US
Practice Address - Phone:623-399-6825
Practice Address - Fax:623-505-3474
Is Sole Proprietor?:No
Enumeration Date:2019-08-05
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1095369133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered