Provider Demographics
NPI:1659029122
Name:KNIGHT, JORDAN ANNE HOSTETLER
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:ANNE HOSTETLER
Last Name:KNIGHT
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 1:5411 ORCHID BLOOM DR
Mailing Address - Street 2:
Mailing Address - City:INDIAN LAND
Mailing Address - State:SC
Mailing Address - Zip Code:29707-6914
Mailing Address - Country:US
Mailing Address - Phone:704-582-1399
Mailing Address - Fax:
Practice Address - Street 1:5411 ORCHID BLOOM DR
Practice Address - Street 2:
Practice Address - City:INDIAN LAND
Practice Address - State:SC
Practice Address - Zip Code:29707-6914
Practice Address - Country:US
Practice Address - Phone:704-582-1399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-14
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL005275133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered