Healthcare Provider Details

I. General information

NPI: 1992822316
Provider Name (Legal Business Name): JESSICA WILSON RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 04/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 SUZANNE WAY STE 200
EUGENE OR
97408-7619
US

IV. Provider business mailing address

650 W 12TH AVE APT 227
EUGENE OR
97402-4087
US

V. Phone/Fax

Practice location:
  • Phone: 541-228-3020
  • Fax:
Mailing address:
  • Phone: 541-228-3020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number962666
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number962666
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: