Provider Demographics
NPI:1972855062
Name:JOHNSON, JORDAN ANNE (MS, RD, CD)
Entity Type:Individual
Prefix:MISS
First Name:JORDAN
Middle Name:ANNE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MS, RD, CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11703 E SPRAGUE AVE
Mailing Address - Street 2:STE C-3
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99206-6128
Mailing Address - Country:US
Mailing Address - Phone:509-921-6560
Mailing Address - Fax:509-921-6551
Practice Address - Street 1:11703 E SPRAGUE AVE
Practice Address - Street 2:STE C-3
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99206-6128
Practice Address - Country:US
Practice Address - Phone:509-921-6560
Practice Address - Fax:509-921-6551
Is Sole Proprietor?:No
Enumeration Date:2012-10-12
Last Update Date:2012-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI60309102133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered