Provider Demographics
NPI:1285905364
Name:WILSON, JENNIFER (RD, LDN)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1919 OVERLAND CT
Mailing Address - Street 2:
Mailing Address - City:ALLISON PARK
Mailing Address - State:PA
Mailing Address - Zip Code:15101-3222
Mailing Address - Country:US
Mailing Address - Phone:412-548-3614
Mailing Address - Fax:
Practice Address - Street 1:9100 BABCOCK BLVD
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15237-5815
Practice Address - Country:US
Practice Address - Phone:412-367-6877
Practice Address - Fax:412-367-5422
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-20
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN000782133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered