Provider Demographics
NPI:1942391925
Name:NELSON, JANICE D
Entity Type:Individual
Prefix:DR
First Name:JANICE
Middle Name:D
Last Name:NELSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JANICE
Other - Middle Name:D
Other - Last Name:NELSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:PO BOX 58264
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84158-0264
Mailing Address - Country:US
Mailing Address - Phone:801-466-8123
Mailing Address - Fax:801-466-8129
Practice Address - Street 1:2319 FOOTHILL DR
Practice Address - Street 2:STE. 275
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84109-1489
Practice Address - Country:US
Practice Address - Phone:801-466-8123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UTUTAH PSYCHOLOGY 207103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000007464Medicare ID - Type UnspecifiedMEDICARE PROVIDER NO.