Healthcare Provider Details

I. General information

NPI: 1871256842
Provider Name (Legal Business Name): JACOB SAMUEL NELSON BHT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JACOB NELSON BHT II

II. Dates (important events)

Enumeration Date: 10/18/2021
Last Update Date: 05/31/2023
Certification Date: 05/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15214 N CAVE CREEK RD STE A
PHOENIX AZ
85032-4360
US

IV. Provider business mailing address

5707 N 44TH LN STE B
GLENDALE AZ
85301-6307
US

V. Phone/Fax

Practice location:
  • Phone: 888-973-2090
  • Fax:
Mailing address:
  • Phone: 800-501-4732
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: