Provider Demographics
NPI:1750007456
Name:WOLF, JESSICA NICOLE (RDN)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:NICOLE
Last Name:WOLF
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 S LUCILE ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98108-2432
Mailing Address - Country:US
Mailing Address - Phone:206-957-1664
Mailing Address - Fax:206-860-6326
Practice Address - Street 1:210 S LUCILE ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98108-2432
Practice Address - Country:US
Practice Address - Phone:206-957-1664
Practice Address - Fax:206-860-6326
Is Sole Proprietor?:No
Enumeration Date:2022-10-13
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61049109133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered