Provider Demographics
NPI:1174558373
Name:JILL HERMAN NELSON, PA
Entity type:Organization
Organization Name:JILL HERMAN NELSON, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JILL
Authorized Official - Middle Name:ANGELA
Authorized Official - Last Name:HERMAN NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:772-285-2227
Mailing Address - Street 1:611 SW FEDERAL HWY
Mailing Address - Street 2:SUITE C
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-2925
Mailing Address - Country:US
Mailing Address - Phone:772-285-2227
Mailing Address - Fax:
Practice Address - Street 1:611 SW FEDERAL HWY
Practice Address - Street 2:SUITE C
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-2925
Practice Address - Country:US
Practice Address - Phone:772-285-2227
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY7022261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL74377Medicare ID - Type Unspecified