Provider Demographics
NPI:1356536221
Name:JORDAN, LAURA LYNN (RD, CD)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:LYNN
Last Name:JORDAN
Suffix:
Gender:F
Credentials:RD, CD
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:LYNN
Other - Last Name:KOSTOPOULOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:3245 HEALTH DR.
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-3245
Mailing Address - Country:US
Mailing Address - Phone:547-647-1840
Mailing Address - Fax:
Practice Address - Street 1:100 NAVARRE PL STE 5550
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1169
Practice Address - Country:US
Practice Address - Phone:574-647-2550
Practice Address - Fax:574-647-1129
Is Sole Proprietor?:No
Enumeration Date:2007-09-13
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37001768A133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN162520056Medicare PIN
IN247000016Medicare PIN
IN236040189Medicare PIN
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IN178420022Medicare PIN
IN245510005Medicare PIN