Healthcare Provider Details

I. General information

NPI: 1003351149
Provider Name (Legal Business Name): MRS. JESSICA NELSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/28/2016
Last Update Date: 01/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1620 CUMMINS DR
MODESTO CA
95358-6400
US

IV. Provider business mailing address

4711 CROWS LANDING RD
MODESTO CA
95358-9487
US

V. Phone/Fax

Practice location:
  • Phone: 209-622-1420
  • Fax:
Mailing address:
  • Phone: 209-872-8078
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberASW75435
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: