Individual
MS. JENNIFER NICOLE WICKWARE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
RD, CD
Contact information
Practice address
1481 W 10TH ST, INDIANAPOLIS, IN 46202-2803
(317) 988-3862
Mailing address
1481 W 10TH ST, INDIANAPOLIS, IN 46202-2803
(317) 988-3862
Taxonomy
Speciality
Code
Description
License number
State
133V00000X
Registered Dietitian
Primary
37001724A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2005032829
MISSOURI STATE LICENSE
MO
01
—
37001724A
DIETITIAN CERTIFICATION
IN
Enumeration date
10/02/2006
Last updated
07/18/2013
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