Provider Demographics
NPI:1992822316
Name:WILSON, JESSICA (RD)
Entity type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:
Last Name:WILSON
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 1:650 W 12TH AVE APT 227
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97402-4087
Mailing Address - Country:US
Mailing Address - Phone:541-228-3020
Mailing Address - Fax:
Practice Address - Street 1:2650 SUZANNE WAY STE 200
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97408-7619
Practice Address - Country:US
Practice Address - Phone:541-228-3020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2014-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR962666133V00000X
CA962666133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered