Provider Demographics
NPI:1902944093
Name:WILCOX, JESSICA ELDREDGE (MNT, MS, RD, LDN)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ELDREDGE
Last Name:WILCOX
Suffix:
Gender:F
Credentials:MNT, MS, RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 S 13TH ST
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:MT
Mailing Address - Zip Code:59047-3727
Mailing Address - Country:US
Mailing Address - Phone:406-823-6604
Mailing Address - Fax:406-823-6602
Practice Address - Street 1:504 S 13TH ST
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:MT
Practice Address - Zip Code:59047-3727
Practice Address - Country:US
Practice Address - Phone:406-823-6604
Practice Address - Fax:406-823-6602
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2014-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT501133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT298738OtherBCBS
MT298738OtherBCBS