Provider Demographics
NPI:1528473089
Name:JESSICA A. WILKS, RD, LDN, INC.
Entity type:Organization
Organization Name:JESSICA A. WILKS, RD, LDN, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILKS
Authorized Official - Suffix:
Authorized Official - Credentials:RD, LDN
Authorized Official - Phone:772-626-4484
Mailing Address - Street 1:1862 SE MORNINGSIDE BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-8818
Mailing Address - Country:US
Mailing Address - Phone:772-626-4484
Mailing Address - Fax:
Practice Address - Street 1:2030 SE OCEAN BLVD
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34996-3304
Practice Address - Country:US
Practice Address - Phone:772-626-4484
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-24
Last Update Date:2014-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND 6950261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service