Basic Information
| Provider Information | |||||||||
| NPI: | 1346622354 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MIZE | ||||||||
| FirstName: | JORDAN | ||||||||
| MiddleName: | D. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MS, RDN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NICHOLS | ||||||||
| OtherFirstName: | JORDAN | ||||||||
| OtherMiddleName: | D. | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 100 MERCY WAY | ||||||||
| Address2: | STE 580 | ||||||||
| City: | JOPLIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648044524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4175568555 | ||||||||
| FaxNumber: | 4175568553 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 MERCY WAY | ||||||||
| Address2: | STE 580 | ||||||||
| City: | JOPLIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648044524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4175568555 | ||||||||
| FaxNumber: | 4175568553 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2015 | ||||||||
| LastUpdateDate: | 12/01/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133VN1006X | 2015020189 | MO | Y | Dietary & Nutritional Service Providers | Dietitian, Registered | Nutrition, Metabolic |
ID Information
| ID | Type | State | Issuer | Description | 1346622354 | 05 | MO | MEDICAID |