Provider Demographics
NPI:1063430833
Name:NELSON, JACALYN A (MD)
Entity type:Individual
Prefix:
First Name:JACALYN
Middle Name:A
Last Name:NELSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2844 INDEX RD
Mailing Address - Street 2:
Mailing Address - City:FITCHBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53713-3117
Mailing Address - Country:US
Mailing Address - Phone:608-229-7979
Mailing Address - Fax:608-229-8110
Practice Address - Street 1:2844 INDEX RD
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:WI
Practice Address - Zip Code:53713-3117
Practice Address - Country:US
Practice Address - Phone:608-229-7979
Practice Address - Fax:608-229-8110
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI49405-20207RS0012X
WI49405-020207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1063430833Medicaid
WI60575OtherDEAN HEALTH INSURANCE
WIP00379512Medicare PIN
G06943Medicare UPIN
WI048154340Medicare PIN
WI016A74150Medicare PIN