Provider Demographics
NPI:1275193880
Name:MILES, JERAD MARTEL (RD)
Entity Type:Individual
Prefix:
First Name:JERAD
Middle Name:MARTEL
Last Name:MILES
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 1:5700 MARKET ST APT 1055
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86314-6513
Mailing Address - Country:US
Mailing Address - Phone:540-498-3007
Mailing Address - Fax:
Practice Address - Street 1:500 AZ-89
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301
Practice Address - Country:US
Practice Address - Phone:928-445-4860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-17
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ86144393133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered