Basic Information
| Provider Information | |||||||||
| NPI: | 1245362599 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NELSON | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | ANN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5579 | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977085579 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5415266635 | ||||||||
| FaxNumber: | 5415266636 | ||||||||
| Practice Location | |||||||||
| Address1: | 340 NW 5TH ST STE 101 | ||||||||
| Address2: | |||||||||
| City: | REDMOND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977561869 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5415266635 | ||||||||
| FaxNumber: | 5415266636 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2007 | ||||||||
| LastUpdateDate: | 04/17/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | 2776314402 | UT | N | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife | 367A00000X | 200850107NP | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
No ID Information.