Provider Demographics
NPI:1104267780
Name:NELSON, JACOB H (DPM)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:H
Last Name:NELSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5432 E SOUTHERN AVE STE 101B
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-2772
Mailing Address - Country:US
Mailing Address - Phone:480-210-3336
Mailing Address - Fax:480-210-3339
Practice Address - Street 1:5432 E SOUTHERN AVE STE 101B
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-2772
Practice Address - Country:US
Practice Address - Phone:480-210-3336
Practice Address - Fax:480-210-3339
Is Sole Proprietor?:No
Enumeration Date:2013-07-11
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0832213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ196499Medicare PIN