Provider Demographics
NPI:1417313008
Name:NELSON, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:BRADLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:533 S 9TH ST
Mailing Address - Street 2:
Mailing Address - City:BERTHOUD
Mailing Address - State:CO
Mailing Address - Zip Code:80513-1400
Mailing Address - Country:US
Mailing Address - Phone:970-412-8037
Mailing Address - Fax:
Practice Address - Street 1:600 W 12TH ST
Practice Address - Street 2:
Practice Address - City:IMPERIAL
Practice Address - State:NE
Practice Address - Zip Code:69033-3130
Practice Address - Country:US
Practice Address - Phone:308-882-7111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-12
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1293225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist