Provider Demographics
NPI:1508645342
Name:NIELSEN, JONATHAN MAXWELL
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:MAXWELL
Last Name:NIELSEN
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:LAKE ORION: 1236 S. LAPEER RD.
Mailing Address - Street 2:
Mailing Address - City:ORION CHARTER TOWNSHIP,
Mailing Address - State:MI
Mailing Address - Zip Code:48360
Mailing Address - Country:US
Mailing Address - Phone:248-929-9220
Mailing Address - Fax:
Practice Address - Street 1:LAKE ORION: 1236 S. LAPEER RD.
Practice Address - Street 2:
Practice Address - City:ORION CHARTER TOWNSHIP,
Practice Address - State:MI
Practice Address - Zip Code:48360
Practice Address - Country:US
Practice Address - Phone:248-929-9220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-21
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156F00000XEye and Vision Services ProvidersTechnician/Technologist