Provider Demographics
NPI:1043633407
Name:NELSON, JONATHAN VINCENT (LCSW)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:VINCENT
Last Name:NELSON
Suffix:
Gender:
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 POLE LINE RD
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-3035
Mailing Address - Country:US
Mailing Address - Phone:208-814-7625
Mailing Address - Fax:
Practice Address - Street 1:601 POLE LINE RD
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-3035
Practice Address - Country:US
Practice Address - Phone:208-814-7625
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-21
Last Update Date:2025-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-374791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1558606962Medicaid