Provider Demographics
NPI:1700043734
Name:NELSON, JACALYN (RPH)
Entity Type:Individual
Prefix:MRS
First Name:JACALYN
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10400 KADLER AVE NE
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:MN
Mailing Address - Zip Code:55362-8165
Mailing Address - Country:US
Mailing Address - Phone:763-389-3111
Mailing Address - Fax:763-389-1621
Practice Address - Street 1:705 NORTHLAND DR
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:MN
Practice Address - Zip Code:55371-2168
Practice Address - Country:US
Practice Address - Phone:763-389-3111
Practice Address - Fax:763-389-1621
Is Sole Proprietor?:No
Enumeration Date:2008-05-19
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1160693183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN132460000Medicaid