Provider Demographics
NPI:1992808430
Name:NELSON, JEAN L (DO)
Entity type:Individual
Prefix:
First Name:JEAN
Middle Name:L
Last Name:NELSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9463 HOLLY RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439
Mailing Address - Country:US
Mailing Address - Phone:810-603-3700
Mailing Address - Fax:810-603-3704
Practice Address - Street 1:9463 HOLLY RD
Practice Address - Street 2:SUITE 103
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439
Practice Address - Country:US
Practice Address - Phone:810-603-3700
Practice Address - Fax:810-603-3704
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2014-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5100010488207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4213465Medicaid
MI0N16890002Medicare ID - Type Unspecified
MI4213465Medicaid