Basic Information
| Provider Information | |||||||||
| NPI: | 1508282153 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCOY | ||||||||
| FirstName: | JORDAN | ||||||||
| MiddleName: | |||||||||
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| Credential: | MS, RD, LD, CSP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1333 W 5TH ST STE 110 | ||||||||
| Address2: | |||||||||
| City: | SHERIDAN | ||||||||
| State: | WY | ||||||||
| PostalCode: | 828012752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076752650 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1333 W 5TH ST STE 112 | ||||||||
| Address2: | |||||||||
| City: | SHERIDAN | ||||||||
| State: | WY | ||||||||
| PostalCode: | 828012752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076752650 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2014 | ||||||||
| LastUpdateDate: | 05/24/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133VN1004X | LD-0958 | NM | N | Dietary & Nutritional Service Providers | Dietitian, Registered | Nutrition, Pediatric | 133V00000X | MED-NUTR-LIC-52027 | MT | N | Dietary & Nutritional Service Providers | Dietitian, Registered | 133V00000X | 158 | WY | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.