MEDICARE: JEREMY DOUGLAS 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	LD006597	GA

General Provider Information

NPI Number	:	1366122293
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEREMY DOUGLAS RDN

Provider Business Mailing Address
First Line	:	4104 PEACHFORD CIR
Second Line	:
City	:	DUNWOODY
State	:	GA
Zip	:	30338-6488
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1380 W MARIETTA ST NW
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30318-4974
Country	:	US
Telephone Number	:	614-738-1343
Fax Number	:

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

Provider Enumeration Date	:	07/25/2023
Last Update Date	:	01/11/2026

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