Provider Demographics
NPI:1902685894
Name:NILSON, JACOB CHRISTIAN (CSW)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:CHRISTIAN
Last Name:NILSON
Suffix:
Gender:M
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3590 HARRISON BLVD STE GL2
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-2060
Mailing Address - Country:US
Mailing Address - Phone:801-644-8229
Mailing Address - Fax:
Practice Address - Street 1:3590 HARRISON BLVD STE GL2
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-2060
Practice Address - Country:US
Practice Address - Phone:801-644-8229
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-28
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
UT13580941-3502101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)