Provider Demographics
NPI:1407239940
Name:NELSON, JENS MONROE
Entity Type:Individual
Prefix:
First Name:JENS
Middle Name:MONROE
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 1:3188 LADD AVE NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-1748
Mailing Address - Country:US
Mailing Address - Phone:503-560-9091
Mailing Address - Fax:503-990-6442
Practice Address - Street 1:4075 32ND PL NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-6754
Practice Address - Country:US
Practice Address - Phone:503-990-6442
Practice Address - Fax:503-990-6442
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-01
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5191133104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness