Provider Demographics
NPI:1992301162
Name:WIKLUND, JESSICA MARIE (MS, RD, LD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:WIKLUND
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1860 WHITE OAK DR
Mailing Address - Street 2:APT 241
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77009-7556
Mailing Address - Country:US
Mailing Address - Phone:832-834-6411
Mailing Address - Fax:
Practice Address - Street 1:1400 8TH AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4110
Practice Address - Country:US
Practice Address - Phone:817-922-1077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-11
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT86452133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered