Provider Demographics
NPI:1629506100
Name:STILMOCK, JORDAN (RD, CLC, LMNT)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:STILMOCK
Suffix:
Gender:F
Credentials:RD, CLC, LMNT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 N 22ND ST
Mailing Address - Street 2:
Mailing Address - City:BLAIR
Mailing Address - State:NE
Mailing Address - Zip Code:68008-1128
Mailing Address - Country:US
Mailing Address - Phone:402-426-1232
Mailing Address - Fax:
Practice Address - Street 1:810 N 22ND ST
Practice Address - Street 2:
Practice Address - City:BLAIR
Practice Address - State:NE
Practice Address - Zip Code:68008-1128
Practice Address - Country:US
Practice Address - Phone:402-426-1232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NEALPP-251862174N00000X
NE86033344133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No174N00000XOther Service ProvidersLactation Consultant, Non-RN