Provider Demographics
NPI:1629738265
Name:JALILI, SHAHRZAD
Entity Type:Individual
Prefix:
First Name:SHAHRZAD
Middle Name:
Last Name:JALILI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9690 S 300 W FL 3
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-3340
Mailing Address - Country:US
Mailing Address - Phone:801-702-3278
Mailing Address - Fax:
Practice Address - Street 1:9690 S 300 W FL 3
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070-3340
Practice Address - Country:US
Practice Address - Phone:801-702-3278
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-22
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT86067089133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered