Provider Demographics
NPI:1700390341
Name:TREVINO, JENNIFER LAUREL (LD RDN)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LAUREL
Last Name:TREVINO
Suffix:
Gender:F
Credentials:LD RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4215 S GRAND CANYON DR STE 101
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89147-7173
Mailing Address - Country:US
Mailing Address - Phone:702-664-1204
Mailing Address - Fax:
Practice Address - Street 1:4215 S GRAND CANYON DR STE 101
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89147-7173
Practice Address - Country:US
Practice Address - Phone:702-664-1204
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-17
Last Update Date:2017-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV39307-DI-0133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty