Provider Demographics
NPI:1396173555
Name:NIELSON, JENNIFER
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:NIELSON
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 1:1711 MELLOR DR
Mailing Address - Street 2:
Mailing Address - City:LAKEPORT
Mailing Address - State:CA
Mailing Address - Zip Code:95453-3413
Mailing Address - Country:US
Mailing Address - Phone:707-263-8795
Mailing Address - Fax:707-263-6561
Practice Address - Street 1:1711 MELLOR DR
Practice Address - Street 2:
Practice Address - City:LAKEPORT
Practice Address - State:CA
Practice Address - Zip Code:95453-3413
Practice Address - Country:US
Practice Address - Phone:707-245-9472
Practice Address - Fax:707-279-8564
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-28
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA105816101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health