Provider Demographics
NPI:1598248486
Name:BADGER, JORDAN LESLIE (RD)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:LESLIE
Last Name:BADGER
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 1:635 COMMONWEALTH AVE FL 6
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-1605
Mailing Address - Country:US
Mailing Address - Phone:617-353-2721
Mailing Address - Fax:
Practice Address - Street 1:635 COMMONWEALTH AVE FL 6
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-1605
Practice Address - Country:US
Practice Address - Phone:617-353-2721
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-07
Last Update Date:2018-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4500133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA4500OtherLICENSED DIETITIAN NUTRITIONIST
86065640OtherREGISTERED DIETITIAN