Provider Demographics
NPI:1477549772
Name:NELSON, JOHN JACK (PT)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:JACK
Last Name:NELSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2710
Mailing Address - Street 2:
Mailing Address - City:GRANITE BAY
Mailing Address - State:CA
Mailing Address - Zip Code:95746-2710
Mailing Address - Country:US
Mailing Address - Phone:916-932-1210
Mailing Address - Fax:
Practice Address - Street 1:700 OAK AVENUE PKWY
Practice Address - Street 2:STE B
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-6871
Practice Address - Country:US
Practice Address - Phone:916-932-1210
Practice Address - Fax:916-932-1205
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-22
Last Update Date:2016-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT23841225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ04666ZOtherGROUP BLUE SHIELD ID
CAOPT238410Medicare ID - Type UnspecifiedINDIVIDUAL MEDICARE#
CAZZZ314823Medicare ID - Type UnspecifiedGROUP MEDICARE #