Provider Demographics
NPI:1568920882
Name:NELSON, JACOB HENRY (DO)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:HENRY
Last Name:NELSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4764 GLENALLEN CT NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97305-3030
Mailing Address - Country:US
Mailing Address - Phone:360-831-3123
Mailing Address - Fax:
Practice Address - Street 1:4764 GLENALLEN CT NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97305-3030
Practice Address - Country:US
Practice Address - Phone:360-831-3123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-05
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0116035953207R00000X
390200000X
ORDO212889208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program