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General NPI Number Information
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NPI Number | 1457948374
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Entity Type | Individual
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Provider Name | NELSON JACO
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Gender | Male
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Dates
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Enumeration Date | 12/26/2020
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Last Update Date | 02/04/2022
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Provider Practice Location Address
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Address Line | 4088 US-91
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City | HYDE PARK
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State | UT
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Zip | 84318
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Country | US
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Telephone | 801-577-4709
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Fax |
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Provider Business Mailing Address
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Address Line | 4088 US-91
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City | HYDE PARK
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State | UT
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Zip | 84318
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Country | US
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Telephone | 801-577-4709
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 9412327-4405
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License Number State | UT
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