Provider Demographics
NPI:1104614734
Name:NELSON, JERMAINE
Entity type:Individual
Prefix:
First Name:JERMAINE
Middle Name:
Last Name:NELSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8807 OLD COLONY WAY APT 2C
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22309-1564
Mailing Address - Country:US
Mailing Address - Phone:216-774-4871
Mailing Address - Fax:
Practice Address - Street 1:8807 OLD COLONY WAY APT 2C
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22309-1564
Practice Address - Country:US
Practice Address - Phone:216-774-4871
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-25
Last Update Date:2025-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program