Provider Demographics
NPI:1992428809
Name:DANSEREAU, JORDAN CAMILLE (RDN, IBCLC)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:CAMILLE
Last Name:DANSEREAU
Suffix:
Gender:F
Credentials:RDN, IBCLC
Other - Prefix:
Other - First Name:JORDAN
Other - Middle Name:CAMILLE
Other - Last Name:PRATT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDN
Mailing Address - Street 1:8500 N ATLAS RD
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-8332
Mailing Address - Country:US
Mailing Address - Phone:208-415-5284
Mailing Address - Fax:208-415-5131
Practice Address - Street 1:8500 N ATLAS RD
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-8332
Practice Address - Country:US
Practice Address - Phone:208-415-5284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-26
Last Update Date:2025-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
L-316372174N00000X
86210366133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No174N00000XOther Service ProvidersLactation Consultant, Non-RN