Provider Demographics
NPI:1063817971
Name:NICHOLSON, MARY JANE
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:JANE
Last Name:NICHOLSON
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 1:1800 EDINBURGH STREET
Mailing Address - Street 2:
Mailing Address - City:RAWLINS
Mailing Address - State:WY
Mailing Address - Zip Code:82301
Mailing Address - Country:US
Mailing Address - Phone:307-324-8820
Mailing Address - Fax:
Practice Address - Street 1:1800 EDINBURGH STREET
Practice Address - Street 2:
Practice Address - City:RAWLINS
Practice Address - State:WYOMING
Practice Address - Zip Code:82301
Practice Address - Country:UM
Practice Address - Phone:307-324-8820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-04
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional