Provider Demographics
NPI:1023884525
Name:JORDAN, MARY-ANGELA (DTR)
Entity type:Individual
Prefix:
First Name:MARY-ANGELA
Middle Name:
Last Name:JORDAN
Suffix:
Gender:F
Credentials:DTR
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:
Other - Last Name:JORDAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DTR
Mailing Address - Street 1:12112 W TETHER TRL
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85383-5872
Mailing Address - Country:US
Mailing Address - Phone:480-267-8767
Mailing Address - Fax:
Practice Address - Street 1:12112 W TETHER TRL
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85383-5872
Practice Address - Country:US
Practice Address - Phone:480-267-8767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-27
Last Update Date:2023-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes136A00000XDietary & Nutritional Service ProvidersDietetic Technician, Registered