Provider Demographics
NPI:1043539612
Name:NICOLAS, JEANETTE IDA
Entity Type:Individual
Prefix:
First Name:JEANETTE
Middle Name:IDA
Last Name:NICOLAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13741 FOOTHILL BLVD STE 270
Mailing Address - Street 2:
Mailing Address - City:SYLMAR
Mailing Address - State:CA
Mailing Address - Zip Code:91342-3150
Mailing Address - Country:US
Mailing Address - Phone:818-833-9789
Mailing Address - Fax:818-833-9790
Practice Address - Street 1:13741 FOOTHILL BLVD STE 270
Practice Address - Street 2:
Practice Address - City:SYLMAR
Practice Address - State:CA
Practice Address - Zip Code:91342-3150
Practice Address - Country:US
Practice Address - Phone:818-833-9789
Practice Address - Fax:818-833-9790
Is Sole Proprietor?:No
Enumeration Date:2010-05-21
Last Update Date:2010-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)