Provider Demographics
NPI:1992111470
Name:NELSON, JOHN (PSYD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:NELSON
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 3RD ST W BLDG 1040
Mailing Address - Street 2:
Mailing Address - City:JBSA RANDOLPH
Mailing Address - State:TX
Mailing Address - Zip Code:78150-4800
Mailing Address - Country:US
Mailing Address - Phone:210-652-2448
Mailing Address - Fax:
Practice Address - Street 1:221 3RD ST W BLDG 1040
Practice Address - Street 2:
Practice Address - City:JBSA RANDOLPH
Practice Address - State:TX
Practice Address - Zip Code:78150-4800
Practice Address - Country:US
Practice Address - Phone:210-652-2448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-07
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28054103TC0700X
103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAN/AMedicaid
CAN/AMedicaid