Provider Demographics
NPI:1457948374
Name:JACO, NELSON
Entity Type:Individual
Prefix:
First Name:NELSON
Middle Name:
Last Name:JACO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4088 US-91
Mailing Address - Street 2:
Mailing Address - City:HYDE PARK
Mailing Address - State:UT
Mailing Address - Zip Code:84318
Mailing Address - Country:US
Mailing Address - Phone:801-577-4709
Mailing Address - Fax:
Practice Address - Street 1:4088 US-91
Practice Address - Street 2:
Practice Address - City:HYDE PARK
Practice Address - State:UT
Practice Address - Zip Code:84318
Practice Address - Country:US
Practice Address - Phone:801-577-4709
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-26
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9412327-4405363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner