Provider Demographics
NPI:1316673437
Name:WALTERS, JENNIFER MICHELLE (RD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MICHELLE
Last Name:WALTERS
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:MICHELLE
Other - Last Name:GALASSO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6040 S FORT APACHE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148-5613
Mailing Address - Country:US
Mailing Address - Phone:702-475-4007
Mailing Address - Fax:702-475-4060
Practice Address - Street 1:6040 S FORT APACHE RD STE 100
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89148-5613
Practice Address - Country:US
Practice Address - Phone:702-475-4007
Practice Address - Fax:702-475-4060
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-29
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV39769DI1133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty