Provider Demographics
NPI:1518304435
Name:NELSON, JARED (OD)
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:
Last Name:NELSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:681 S GRANT LN
Mailing Address - Street 2:
Mailing Address - City:NORTH SALT LAKE
Mailing Address - State:UT
Mailing Address - Zip Code:84054-1204
Mailing Address - Country:US
Mailing Address - Phone:435-720-3280
Mailing Address - Fax:
Practice Address - Street 1:UNIT 28130 BOX USAHC
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09114-8130
Practice Address - Country:US
Practice Address - Phone:314-590-3207
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-01
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD60401345152W00000X
UT8684413-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist