Provider Demographics
NPI:1548146186
Name:NELSON, JENESIS JADAYAH (LPN)
Entity type:Individual
Prefix:
First Name:JENESIS
Middle Name:JADAYAH
Last Name:NELSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2107 PIKE ST
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-7008
Mailing Address - Country:US
Mailing Address - Phone:573-714-1516
Mailing Address - Fax:
Practice Address - Street 1:2107 PIKE ST
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-7008
Practice Address - Country:US
Practice Address - Phone:573-714-1516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-11
Last Update Date:2025-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1123849164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse