MEDICARE: MRS. JESSICA ANN NELSON BSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist

General Provider Information

NPI Number	:	1831385459
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JESSICA ANN NELSON BSW

Provider Business Mailing Address
First Line	:	123 TRUXTON AVE
Second Line	:
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32547-2460
Country	:	US
Telephone Number	:	850-863-1530
Fax Number	:	850-863-5548

Provider Business Practice Location Address
First Line	:	123 TRUXTON AVE
Second Line	:
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32547-2460
Country	:	US
Telephone Number	:	850-863-1530
Fax Number	:	850-863-5548

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/18/2007
Last Update Date	:	03/10/2008

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