Provider Demographics
NPI:1487219986
Name:NELSON, JESSICA KATHLEEN
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:KATHLEEN
Last Name:NELSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:74923 HOVLEY LN E
Mailing Address - Street 2:
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92260-1927
Mailing Address - Country:US
Mailing Address - Phone:760-347-0754
Mailing Address - Fax:760-770-2240
Practice Address - Street 1:74923 HOVLEY LN E
Practice Address - Street 2:
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92260-1927
Practice Address - Country:US
Practice Address - Phone:760-347-0754
Practice Address - Fax:760-770-2240
Is Sole Proprietor?:No
Enumeration Date:2019-05-09
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist