Provider Demographics
NPI:1699320960
Name:WIBLE, JENNIFER (RD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:WIBLE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1309 GOLDILOCKS LN
Mailing Address - Street 2:
Mailing Address - City:MANCHACA
Mailing Address - State:TX
Mailing Address - Zip Code:78652-4532
Mailing Address - Country:US
Mailing Address - Phone:404-825-7331
Mailing Address - Fax:866-533-2028
Practice Address - Street 1:1309 GOLDILOCKS LN
Practice Address - Street 2:
Practice Address - City:MANCHACA
Practice Address - State:TX
Practice Address - Zip Code:78652-4532
Practice Address - Country:US
Practice Address - Phone:512-522-6136
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-05
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered