Provider Demographics
NPI:1528293586
Name:WILSON, JOLEEN (RD/LD)
Entity type:Individual
Prefix:
First Name:JOLEEN
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:RD/LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 S MAIN ST
Mailing Address - Street 2:PMB 2735
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74013-9701
Mailing Address - Country:US
Mailing Address - Phone:918-280-8456
Mailing Address - Fax:855-438-6802
Practice Address - Street 1:6336 S 116TH EAST AVE
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-1251
Practice Address - Country:US
Practice Address - Phone:918-280-8456
Practice Address - Fax:855-438-6802
Is Sole Proprietor?:No
Enumeration Date:2009-05-20
Last Update Date:2023-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1842133V00000X, 133V00000X
LA2971133V00000X
KS1736133V00000X
MN4372133V00000X
NE1377133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1842OtherLD
LA2971OtherLD