Healthcare Provider Details

I. General information

NPI: 1033740865
Provider Name (Legal Business Name): JACKIE NELSON, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2020
Last Update Date: 01/30/2020
Certification Date: 01/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 N 9TH ST STE 401C
BOISE ID
83702-5770
US

IV. Provider business mailing address

4621 W KENDALL ST
BOISE ID
83706-2222
US

V. Phone/Fax

Practice location:
  • Phone: 208-639-9192
  • Fax:
Mailing address:
  • Phone: 480-316-5462
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JACQUELYN NELSON
Title or Position: OWNER AND COUNSELOR
Credential: M.S.C, LCPC
Phone: 480-316-5462