Basic Information
| Provider Information | |||||||||
| NPI: | 1427624816 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BIERMAN | ||||||||
| FirstName: | JORDAN | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | RD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 25608 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841250608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063204476 | ||||||||
| FaxNumber: | 2065687043 | ||||||||
| Practice Location | |||||||||
| Address1: | 1101 MADISON ST STE 800 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981041307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2062152700 | ||||||||
| FaxNumber: | 2062152702 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2021 | ||||||||
| LastUpdateDate: | 08/09/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133VN1004X | DI61160753 | WA | N | Dietary & Nutritional Service Providers | Dietitian, Registered | Nutrition, Pediatric | 133V00000X | DI61160753 | WA | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 86113215 | 01 | COMMISSION ON DIETETIC REGISTRATION | OTHER | 08695 | 01 | OH | DIETITIAN LICENSE | OTHER |