Provider Demographics
NPI:1073774766
Name:WELLNER, JODI (RD)
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:
Last Name:WELLNER
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 66308
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77266-6308
Mailing Address - Country:US
Mailing Address - Phone:713-830-3060
Mailing Address - Fax:713-523-4897
Practice Address - Street 1:3311 RICHMOND AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77098
Practice Address - Country:US
Practice Address - Phone:713-830-3033
Practice Address - Fax:713-523-4897
Is Sole Proprietor?:No
Enumeration Date:2008-06-24
Last Update Date:2011-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT07555133V00000X
TX952398133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX184297301Medicaid
TX184297301Medicaid