Provider Demographics
NPI:1992428809
Name:PRATT, JORDAN CAMILLE (RDN)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:CAMILLE
Last Name:PRATT
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14898 N BOXWOOD ST
Mailing Address - Street 2:
Mailing Address - City:RATHDRUM
Mailing Address - State:ID
Mailing Address - Zip Code:83858-8235
Mailing Address - Country:US
Mailing Address - Phone:509-554-2997
Mailing Address - Fax:
Practice Address - Street 1:14898 N BOXWOOD ST
Practice Address - Street 2:
Practice Address - City:RATHDRUM
Practice Address - State:ID
Practice Address - Zip Code:83858-8235
Practice Address - Country:US
Practice Address - Phone:509-554-2997
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-26
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86210366133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered