Provider Demographics
NPI:1558669358
Name:PONDS, JEREMY THOMAS
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:THOMAS
Last Name:PONDS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:736 SHADOWBROOK DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29210-3751
Mailing Address - Country:US
Mailing Address - Phone:803-575-0468
Mailing Address - Fax:
Practice Address - Street 1:147 VERA RD STE A
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-3756
Practice Address - Country:US
Practice Address - Phone:803-575-0468
Practice Address - Fax:803-728-3224
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-03
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC638133N00000X, 133VN1004X
NCL006090133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist
No133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC20B5KOtherBCBS NC
SCDT1055Medicaid