Provider Demographics
NPI:1659545879
Name:NELSON, JACK ORRIN (PT)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:ORRIN
Last Name:NELSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 COUNTY ROAD G
Mailing Address - Street 2:
Mailing Address - City:SPOONER
Mailing Address - State:WI
Mailing Address - Zip Code:54801-8967
Mailing Address - Country:US
Mailing Address - Phone:715-635-9769
Mailing Address - Fax:
Practice Address - Street 1:19 W NEWTON ST
Practice Address - Street 2:
Practice Address - City:RICE LAKE
Practice Address - State:WI
Practice Address - Zip Code:54868-1744
Practice Address - Country:US
Practice Address - Phone:715-234-2161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-18
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10344-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist