Provider Demographics
NPI:1619449766
Name:LICHTHARDT, JORDAN A
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:A
Last Name:LICHTHARDT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3917 WEST RD STE A
Mailing Address - Street 2:
Mailing Address - City:LOS ALAMOS
Mailing Address - State:NM
Mailing Address - Zip Code:87544-2292
Mailing Address - Country:US
Mailing Address - Phone:505-661-8900
Mailing Address - Fax:505-661-8916
Practice Address - Street 1:3917 WEST RD STE A
Practice Address - Street 2:
Practice Address - City:LOS ALAMOS
Practice Address - State:NM
Practice Address - Zip Code:87544-2292
Practice Address - Country:US
Practice Address - Phone:505-661-8900
Practice Address - Fax:505-661-8916
Is Sole Proprietor?:No
Enumeration Date:2018-12-28
Last Update Date:2018-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMLD-1195133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered