Provider Demographics
NPI:1831398387
Name:THIBOUTOT, JEFF R (BS, CN)
Entity type:Individual
Prefix:
First Name:JEFF
Middle Name:R
Last Name:THIBOUTOT
Suffix:
Gender:M
Credentials:BS, CN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:952 E BASELINE RD
Mailing Address - Street 2:SUITE 119
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85204-6627
Mailing Address - Country:US
Mailing Address - Phone:480-539-4041
Mailing Address - Fax:480-539-4293
Practice Address - Street 1:952 E BASELINE RD
Practice Address - Street 2:SUITE 119
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-6627
Practice Address - Country:US
Practice Address - Phone:480-539-4041
Practice Address - Fax:480-539-4293
Is Sole Proprietor?:No
Enumeration Date:2007-07-15
Last Update Date:2007-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education