Provider Demographics
NPI:1710104336
Name:WILSON, JENNIFER ALLEN (RD)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:ALLEN
Last Name:WILSON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:MISS
Other - First Name:JENNIFER
Other - Middle Name:LOUISE
Other - Last Name:ALLEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 758997
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21275-0001
Mailing Address - Country:US
Mailing Address - Phone:804-828-2841
Mailing Address - Fax:804-628-0783
Practice Address - Street 1:1250 E. MARSHALL STREET
Practice Address - Street 2:CLINICAL NUTRITION
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23298-0294
Practice Address - Country:US
Practice Address - Phone:804-828-0970
Practice Address - Fax:804-628-0921
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered