Provider Demographics
NPI:1083978837
Name:NICHOLAS, JENNIFER LYNN (FNP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:NICHOLAS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1433 5TH ST
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:WA
Mailing Address - Zip Code:99403-2714
Mailing Address - Country:US
Mailing Address - Phone:509-758-5141
Mailing Address - Fax:509-758-5299
Practice Address - Street 1:1433 5TH ST
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:WA
Practice Address - Zip Code:99403-2714
Practice Address - Country:US
Practice Address - Phone:509-758-5141
Practice Address - Fax:509-758-5299
Is Sole Proprietor?:No
Enumeration Date:2012-06-26
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60299874363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner