=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033740865
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JACKIE NELSON, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/30/2020
-----------------------------------------------------
Last Update Date | 01/30/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 202 N 9TH ST STE 401C
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83702-5770
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-639-9192
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4621 W KENDALL ST
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83706-2222
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-316-5462
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER AND COUNSELOR
-----------------------------------------------------
Name | JACQUELYN NELSON
-----------------------------------------------------
Credential | M.S.C, LCPC
-----------------------------------------------------
Telephone | 480-316-5462
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------