Provider Demographics
NPI:1346622412
Name:NELSON, ALEX JACKSON
Entity Type:Individual
Prefix:
First Name:ALEX
Middle Name:JACKSON
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 1:3217 HENNEPIN AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-4694
Mailing Address - Country:US
Mailing Address - Phone:612-235-6743
Mailing Address - Fax:
Practice Address - Street 1:3217 HENNEPIN AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-4694
Practice Address - Country:US
Practice Address - Phone:612-235-6743
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-24
Last Update Date:2015-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN23714101YM0800X
MD19500101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health