Provider Demographics
NPI:1811319403
Name:NELSON, JASON M (PHD)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:M
Last Name:NELSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1041 CREEK FARM RUN
Mailing Address - Street 2:
Mailing Address - City:BOGART
Mailing Address - State:GA
Mailing Address - Zip Code:30622-2791
Mailing Address - Country:US
Mailing Address - Phone:706-612-4947
Mailing Address - Fax:706-548-8698
Practice Address - Street 1:105A CEDAR ROCK TRACE
Practice Address - Street 2:SUITE 5
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30605
Practice Address - Country:US
Practice Address - Phone:706-548-8697
Practice Address - Fax:706-548-8698
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-15
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA3266103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist