Provider Demographics
NPI:1952823171
Name:SHANKS, JERI KENDAL (RDN)
Entity Type:Individual
Prefix:
First Name:JERI
Middle Name:KENDAL
Last Name:SHANKS
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1564
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85211-1564
Mailing Address - Country:US
Mailing Address - Phone:480-294-6543
Mailing Address - Fax:480-294-6544
Practice Address - Street 1:1237 S VAL VISTA DR
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204
Practice Address - Country:US
Practice Address - Phone:480-294-6543
Practice Address - Fax:480-294-6544
Is Sole Proprietor?:No
Enumeration Date:2017-07-10
Last Update Date:2018-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ86053981OtherCOMMISSION ON DIETETIC REGISTRATION