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NPI Code Detail

MEDICARE: JENNIFER L WILSON RD, LDN

MEDICARE: JENNIFER L WILSON RD, LDN
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
1133V00000XRegistered Dietitian1011989

General Provider Information

NPI Number : 1881282846
Entity Type Code : Individual
Provider Name (Legal Business Name) : JENNIFER L WILSON RD, LDN
Provider Business Mailing Address
First Line : 2632 N MOZART ST APT 2
Second Line :
City : CHICAGO
State : IL
Zip : 60647-5708
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 225 E CHICAGO AVE
Second Line :
City : CHICAGO
State : IL
Zip : 60611-2991
Country : US
Telephone Number : 312-227-6859
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/05/2021
Last Update Date : 01/05/2021

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Directions to “ JENNIFER L WILSON RD, LDN” Practice Location

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