Provider Demographics
NPI:1346604691
Name:NELSON, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 FOX RUN CIR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80921-3032
Mailing Address - Country:US
Mailing Address - Phone:719-271-4317
Mailing Address - Fax:
Practice Address - Street 1:515 FOX RUN CIR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80921-3032
Practice Address - Country:US
Practice Address - Phone:719-271-4317
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-12
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2065XRespite Care FacilityRespite CareRespite Care, Physical Disabilities, Child
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO99986361Medicaid