Provider Demographics
NPI:1629210935
Name:NELSON, JACQUELYNN DEANN
Entity Type:Individual
Prefix:MS
First Name:JACQUELYNN
Middle Name:DEANN
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 1:3434 GROVE STREET
Mailing Address - Street 2:
Mailing Address - City:LEMON GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:91945-3822
Mailing Address - Country:US
Mailing Address - Phone:406-261-1068
Mailing Address - Fax:
Practice Address - Street 1:3434 GROVE STREET
Practice Address - Street 2:
Practice Address - City:LEMON GROVE
Practice Address - State:CA
Practice Address - Zip Code:91945-3822
Practice Address - Country:US
Practice Address - Phone:406-261-1068
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-01
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No251S00000XAgenciesCommunity/Behavioral Health