Provider Demographics
NPI:1043353717
Name:NELSON, JAKOB JAMES (MA, PHD)
Entity type:Individual
Prefix:DR
First Name:JAKOB
Middle Name:JAMES
Last Name:NELSON
Suffix:
Gender:M
Credentials:MA, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4329 CHARLOTTE ST
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64110-1548
Mailing Address - Country:US
Mailing Address - Phone:816-531-2264
Mailing Address - Fax:
Practice Address - Street 1:300 W 19TH TER
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64108-2026
Practice Address - Country:US
Practice Address - Phone:816-404-6295
Practice Address - Fax:816-404-6318
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X
MO2007011137103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO490205101Medicaid