Provider Information for 1629550744
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Mr. JONATHAN RICHARD NELSON III LCSW, MCAP
Sex: Male
NPI: 1629550744
Last Updated: 2018-09-15
Certification Date:
Certification Date:
Details
| Name | Value | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| NPI | 1629550744 | ||||||||||||
| Enumeration Date | 2018-09-05 | ||||||||||||
| NPI Type | NPI-1 Individual | ||||||||||||
| Sole Proprietor | YES | ||||||||||||
| Status | Active | ||||||||||||
| Mailing Address | 900 N SWALLOW TAIL DR STE 105 PORT ORANGE, FL 32129-6103 United States Phone: 386-333-9717 | Fax: | ||||||||||||
| Primary Practice Address | 900 N SWALLOW TAIL DR STE 105 PORT ORANGE, FL 32129-6103 United States Phone: 386-333-9717 | Fax: | ||||||||||||
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