Provider Demographics
NPI:1356986079
Name:WINGATE, JORDAN MILLER (MS, RD, LDN)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:MILLER
Last Name:WINGATE
Suffix:
Gender:
Credentials:MS, RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 PINE MEADOWS CIR
Mailing Address - Street 2:
Mailing Address - City:HICKORY
Mailing Address - State:NC
Mailing Address - Zip Code:28601-8624
Mailing Address - Country:US
Mailing Address - Phone:336-328-5712
Mailing Address - Fax:
Practice Address - Street 1:1900 3RD AVENUE LN SE
Practice Address - Street 2:
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28602-2959
Practice Address - Country:US
Practice Address - Phone:828-304-0102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-18
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC86072145133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered