Provider Demographics
NPI:1225303233
Name:CROSSWHITE, JENNIFER (RD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:CROSSWHITE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:FUJIMOTO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6536 BLACK OAKS ST
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89084-2045
Mailing Address - Country:US
Mailing Address - Phone:702-505-5147
Mailing Address - Fax:
Practice Address - Street 1:4700 LAS VEGAS BLVD N
Practice Address - Street 2:
Practice Address - City:NELLIS AFB
Practice Address - State:NV
Practice Address - Zip Code:89191-6600
Practice Address - Country:US
Practice Address - Phone:702-653-3679
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-09
Last Update Date:2012-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV860006266133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered