Healthcare Provider Details

I. General information

NPI: 1134655848
Provider Name (Legal Business Name): JODI NELSON DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2017
Last Update Date: 01/18/2024
Certification Date: 01/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 N ROBERTSON BLVD STE 202
BEVERLY HILLS CA
90211-6002
US

IV. Provider business mailing address

200 N ROBERTSON BLVD STE 202
BEVERLY HILLS CA
90211-6002
US

V. Phone/Fax

Practice location:
  • Phone: 310-423-3277
  • Fax:
Mailing address:
  • Phone: 310-385-6016
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number0000000000
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number5101026014
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code2084N0008X
TaxonomyNeuromuscular Medicine (Psychiatry & Neurology) Physician
License Number20A20079
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: