Basic Information
| Provider Information | |||||||||
| NPI: | 1407802515 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NELSON | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | J. | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 789 CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | DOVER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038202526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6037404478 | ||||||||
| FaxNumber: | 6037402244 | ||||||||
| Practice Location | |||||||||
| Address1: | 19 LEVESQUE DR | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | ELIOT | ||||||||
| State: | ME | ||||||||
| PostalCode: | 039032079 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2074519600 | ||||||||
| FaxNumber: | 2074519603 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 0355392303 | NH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | ME | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 30011559 | 05 | NH | MEDICAID | 282640099 | 05 | ME | MEDICAID | MN0364492 | 01 | NH | DEA | OTHER |