Provider Demographics
NPI:1720232499
Name:NELSON, JAY MICHAEL (LMT, CADCI)
Entity Type:Individual
Prefix:MR
First Name:JAY
Middle Name:MICHAEL
Last Name:NELSON
Suffix:
Gender:M
Credentials:LMT, CADCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 SE 5TH AVE STE C
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97123-4095
Mailing Address - Country:US
Mailing Address - Phone:503-543-6100
Mailing Address - Fax:503-648-5269
Practice Address - Street 1:134 SE 5TH AVE STE C
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97123-4095
Practice Address - Country:US
Practice Address - Phone:503-543-6100
Practice Address - Fax:503-214-8911
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-07
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR8086172V00000X
OR08-12-37101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR278095Medicaid
OR1042985OtherASHNET - AMERICAN SPECIALTY HEALTH NETWORK