MEDICARE: JENNIFER LAUREL TREVINO LD RDN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	39307-DI-0	NV

General Provider Information

NPI Number	:	1700390341
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER LAUREL TREVINO LD RDN

Provider Business Mailing Address
First Line	:	4215 S GRAND CANYON DR STE 101
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89147-7173
Country	:	US
Telephone Number	:	702-664-1204
Fax Number	:

Provider Business Practice Location Address
First Line	:	4215 S GRAND CANYON DR STE 101
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89147-7173
Country	:	US
Telephone Number	:	702-664-1204
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/17/2017
Last Update Date	:	11/17/2017

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