Provider Demographics
NPI:1073674230
Name:NELSON, JAY WOODWORTH (OD)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:WOODWORTH
Last Name:NELSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:625 BLACK LAKE BLVD SW
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-5066
Mailing Address - Country:US
Mailing Address - Phone:360-943-2334
Mailing Address - Fax:360-943-2879
Practice Address - Street 1:625 BLACK LAKE BLVD SW
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-5066
Practice Address - Country:US
Practice Address - Phone:360-943-2334
Practice Address - Fax:360-943-2879
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1339152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist