Healthcare Provider Details

I. General information

NPI: 1639338833
Provider Name (Legal Business Name): DR. JESSICA ANN NELSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2008
Last Update Date: 02/18/2020
Certification Date: 02/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 CLARKSON ST
BRIDGEPORT CT
06605-3240
US

IV. Provider business mailing address

120 CLARKSON ST
BRIDGEPORT CT
06605-3240
US

V. Phone/Fax

Practice location:
  • Phone: 714-871-5646
  • Fax: 714-817-7368
Mailing address:
  • Phone: 310-704-8679
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number2334
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: