Provider Demographics
NPI:1043914393
Name:NELSON, JEFFERY ALLEN
Entity Type:Individual
Prefix:
First Name:JEFFERY
Middle Name:ALLEN
Last Name:NELSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6465 WAYZATA BLVD STE 710
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55426-1733
Mailing Address - Country:US
Mailing Address - Phone:612-735-8002
Mailing Address - Fax:651-413-3003
Practice Address - Street 1:6465 WAYZATA BLVD STE 710
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426-1733
Practice Address - Country:US
Practice Address - Phone:612-735-8002
Practice Address - Fax:651-413-3003
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-29
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3923106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty