Provider Demographics
NPI:1154842136
Name:NELSON, JACOB E (PT)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:E
Last Name:NELSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:JAKE
Other - Middle Name:
Other - Last Name:NELSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:2839 W KENNEWICK AVE # 550
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-2927
Mailing Address - Country:US
Mailing Address - Phone:509-783-8977
Mailing Address - Fax:509-783-6151
Practice Address - Street 1:6699 W RIO GRANDE AVE
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-3301
Practice Address - Country:US
Practice Address - Phone:509-460-5588
Practice Address - Fax:509-783-5438
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-29
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60770297261QP2000X
WA225100000X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic