Provider Demographics
NPI:1700188653
Name:WILKE, JENNIFER ANNE (MS, RD, CED-S, CSSD)
Entity Type:Individual
Prefix:MISS
First Name:JENNIFER
Middle Name:ANNE
Last Name:WILKE
Suffix:
Gender:F
Credentials:MS, RD, CED-S, CSSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5121 S COTTONWOOD ST
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-5701
Mailing Address - Country:US
Mailing Address - Phone:435-901-0644
Mailing Address - Fax:
Practice Address - Street 1:5373 S GREEN ST STE 400
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84123-4740
Practice Address - Country:US
Practice Address - Phone:801-442-2615
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-29
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12044801-4901133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered