Healthcare Provider Details

I. General information

NPI: 1558188995
Provider Name (Legal Business Name): YINCHEN JENNY CHEN WILDMAN RDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JENNY CHEN RDN

II. Dates (important events)

Enumeration Date: 09/25/2024
Last Update Date: 09/25/2024
Certification Date: 09/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2472 VISTA GRANDE
FAIRFIELD CA
94534-7507
US

IV. Provider business mailing address

2472 VISTA GRANDE
FAIRFIELD CA
94534-7507
US

V. Phone/Fax

Practice location:
  • Phone: 574-323-0619
  • Fax:
Mailing address:
  • Phone: 574-323-0619
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86020612
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: