Provider Demographics
NPI:1427639459
Name:LIBONATI, JERROD PAUL (RD)
Entity type:Individual
Prefix:
First Name:JERROD
Middle Name:PAUL
Last Name:LIBONATI
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 S DECATUR BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89107-2936
Mailing Address - Country:US
Mailing Address - Phone:702-759-0953
Mailing Address - Fax:
Practice Address - Street 1:280 S DECATUR BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89107-2936
Practice Address - Country:US
Practice Address - Phone:702-759-0953
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-20
Last Update Date:2021-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA911745133V00000X
NV39960-DI-0133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV39960-DI-0Medicaid
CA911745Medicaid