Provider Demographics
NPI:1982831947
Name:NELSON, JASON D (CNP)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:D
Last Name:NELSON
Suffix:
Gender:M
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 N 6TH AVE E
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-1952
Mailing Address - Country:US
Mailing Address - Phone:218-249-7000
Mailing Address - Fax:218-249-7050
Practice Address - Street 1:220 N 6TH AVE E
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55805-1952
Practice Address - Country:US
Practice Address - Phone:218-249-7000
Practice Address - Fax:218-249-7050
Is Sole Proprietor?:No
Enumeration Date:2009-06-17
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR175110-9363L00000X
MNR-175110-9363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNR1751109Medicaid