Provider Demographics
NPI:1073801676
Name:NELSON, JENNIFER RAE (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:RAE
Last Name:NELSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:336 DEERFIELD RD
Mailing Address - Street 2:
Mailing Address - City:BOONE
Mailing Address - State:NC
Mailing Address - Zip Code:28607-5008
Mailing Address - Country:US
Mailing Address - Phone:828-262-4133
Mailing Address - Fax:828-262-4103
Practice Address - Street 1:336 DEERFIELD RD
Practice Address - Street 2:
Practice Address - City:BOONE
Practice Address - State:NC
Practice Address - Zip Code:28607-5008
Practice Address - Country:US
Practice Address - Phone:828-262-4133
Practice Address - Fax:828-262-4103
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-16
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT200077207P00000X, 207R00000X
PAMD451898207P00000X
NC2015-02255207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine