Provider Demographics
NPI:1871256842
Name:NELSON, JACOB SAMUEL (BHT)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:SAMUEL
Last Name:NELSON
Suffix:
Gender:M
Credentials:BHT
Other - Prefix:
Other - First Name:JACOB
Other - Middle Name:
Other - Last Name:NELSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:BHT II
Mailing Address - Street 1:5707 N 44TH LN STE B
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85301-6307
Mailing Address - Country:US
Mailing Address - Phone:800-501-4732
Mailing Address - Fax:
Practice Address - Street 1:15214 N CAVE CREEK RD STE A
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-4360
Practice Address - Country:US
Practice Address - Phone:888-973-2090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-18
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ175T00000X, 106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty