Provider Demographics
NPI:1295772879
Name:NELSON, JENNIFER L (DO)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:NELSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:716 E 19TH ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105
Mailing Address - Country:US
Mailing Address - Phone:605-444-8650
Mailing Address - Fax:605-444-8651
Practice Address - Street 1:716 E 19TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105
Practice Address - Country:US
Practice Address - Phone:605-444-8650
Practice Address - Fax:605-444-8651
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN101467207Q00000X
SD5496207Q00000X
MN47059207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD4993299OtherBLUE CROSS BLUE SHIELD
SD5612862Medicaid
SD43Z306Medicare PIN
SD4993299OtherBLUE CROSS BLUE SHIELD
SDS40004Medicare PIN
SD431306Medicare PIN
SDS102483Medicare PIN
I17537Medicare UPIN
SDS106802Medicare UPIN
SDS30026Medicare PIN