Provider Demographics
NPI:1841436656
Name:NELSON, JEREMY DAVID (MPT)
Entity type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:DAVID
Last Name:NELSON
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13330 VIA BELLARADO
Mailing Address - Street 2:UNIT 1
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92129-5158
Mailing Address - Country:US
Mailing Address - Phone:619-997-5552
Mailing Address - Fax:
Practice Address - Street 1:13330 VIA BELLARADO
Practice Address - Street 2:UNIT 1
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92129-5158
Practice Address - Country:US
Practice Address - Phone:619-997-5552
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-29
Last Update Date:2014-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23510225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA23510OtherCALIFORNIA STATE LICENSE