Provider Demographics
NPI:1417461849
Name:NELSON, JACKIE (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11603 CRESTON
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78251-3219
Mailing Address - Country:US
Mailing Address - Phone:210-378-5763
Mailing Address - Fax:
Practice Address - Street 1:2200 EDISON ST
Practice Address - Street 2:
Practice Address - City:BRUSH
Practice Address - State:CO
Practice Address - Zip Code:80723-1609
Practice Address - Country:US
Practice Address - Phone:210-378-5763
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-21
Last Update Date:2017-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0002839235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist