Provider Demographics
NPI:1043961550
Name:AT YOUR SERVICE BY NICOLE
Entity Type:Organization
Organization Name:AT YOUR SERVICE BY NICOLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:N
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-727-8384
Mailing Address - Street 1:1440 TEABERRY CIR
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-2123
Mailing Address - Country:US
Mailing Address - Phone:678-727-8384
Mailing Address - Fax:
Practice Address - Street 1:1440 TEABERRY CIR
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30044-2123
Practice Address - Country:US
Practice Address - Phone:678-727-8384
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-16
Last Update Date:2022-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health