Provider Demographics
NPI:1134370265
Name:NELSON, RONN JEFFRY II (PSYD)
Entity type:Individual
Prefix:DR
First Name:RONN
Middle Name:JEFFRY
Last Name:NELSON
Suffix:II
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 1:3405 SW 13TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-2923
Mailing Address - Country:US
Mailing Address - Phone:503-476-4929
Mailing Address - Fax:
Practice Address - Street 1:1700 NW CIVIC DR
Practice Address - Street 2:SUITE 310
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-3770
Practice Address - Country:US
Practice Address - Phone:503-476-4929
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-07
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2041103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical