Provider Demographics
NPI:1609034149
Name:NELSON, JENNIFER NICOLE (MS CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:NICOLE
Last Name:NELSON
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21828 E CREOSOTE DR
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85142-4931
Mailing Address - Country:US
Mailing Address - Phone:801-362-5576
Mailing Address - Fax:
Practice Address - Street 1:3507 S RANCH HOUSE PKWY
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85297-4945
Practice Address - Country:US
Practice Address - Phone:480-279-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-31
Last Update Date:2010-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4164458235Z00000X
AZSLP6233235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist