Provider Demographics
NPI:1104450360
Name:WILL, JEREMY (RD/LD)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:WILL
Suffix:
Gender:M
Credentials:RD/LD
Other - Prefix:
Other - First Name:JEREMY
Other - Middle Name:
Other - Last Name:WILL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RD/LD
Mailing Address - Street 1:241 CASORIA AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89123-7401
Mailing Address - Country:US
Mailing Address - Phone:773-329-0648
Mailing Address - Fax:
Practice Address - Street 1:2075 E FLAMINGO RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-5188
Practice Address - Country:US
Practice Address - Phone:702-733-8800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-26
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV39368-DI-0133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered