Provider Demographics
NPI:1992004451
Name:SMITH, JEREMY CLINTON (RD)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:CLINTON
Last Name:SMITH
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 1:304 BLAINE AVE
Mailing Address - Street 2:
Mailing Address - City:CLOQUET
Mailing Address - State:MN
Mailing Address - Zip Code:55720-1202
Mailing Address - Country:US
Mailing Address - Phone:218-878-0646
Mailing Address - Fax:
Practice Address - Street 1:304 BLAINE AVE
Practice Address - Street 2:
Practice Address - City:CLOQUET
Practice Address - State:MN
Practice Address - Zip Code:55720-1202
Practice Address - Country:US
Practice Address - Phone:218-878-0646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-23
Last Update Date:2011-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered