Individual
JORDAN DOMENICK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
RD
Contact information
Practice address
1061 HARMON AVE, FORT STEWART, GA 31314-5641
(912) 435-6633
Mailing address
1061 HARMON AVE, FORT STEWART, GA 31314-5641
(314) 691-3721
Taxonomy
Speciality
Code
Description
License number
State
133V00000X
Registered Dietitian
Primary
2022036290
MO
133V00000X
Registered Dietitian
4237
MN
Other
Enumeration date
06/04/2021
Last updated
12/28/2023
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