Provider Demographics
NPI:1912925017
Name:NELSON, JENNIFER MARIE (MA)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:MARIE
Last Name:NELSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:MS
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:RIVERS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA, LMHC, CDP
Mailing Address - Street 1:8085 WAYZATA BLVD SUITE 215
Mailing Address - Street 2:
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55426
Mailing Address - Country:US
Mailing Address - Phone:206-947-2645
Mailing Address - Fax:651-493-2798
Practice Address - Street 1:8085 WAYZATA BLVD SUITE 215
Practice Address - Street 2:
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55426
Practice Address - Country:US
Practice Address - Phone:206-947-2645
Practice Address - Fax:651-493-2798
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00008407101Y00000X, 101YM0800X, 251S00000X
WACP60181716101YA0400X
MN00212101YP2500X
MN02466251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1912925017Medicaid