Basic Information
| Provider Information | |||||||||
| NPI: | 1730778028 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BELLEW | ||||||||
| FirstName: | JORDAN | ||||||||
| MiddleName: | ALEXANDER | ||||||||
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| Credential: | MS, RD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 497 | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | AR | ||||||||
| PostalCode: | 720060497 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8703472534 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8924 KANIS RD | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722056414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5014552712 | ||||||||
| FaxNumber: | 5014552781 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2021 | ||||||||
| LastUpdateDate: | 07/06/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | N | Dietary & Nutritional Service Providers | Dietitian, Registered | 133V00000X | 2039 | AR | N | Dietary & Nutritional Service Providers | Dietitian, Registered | 133V00000X | 2009 | AR | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.