Provider Demographics
NPI:1174688469
Name:NICOL, JOHN ELKANAH
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ELKANAH
Last Name:NICOL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 DANIELS AVE
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94590-3014
Mailing Address - Country:US
Mailing Address - Phone:707-552-7961
Mailing Address - Fax:
Practice Address - Street 1:5063 MIDWAY RD
Practice Address - Street 2:
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95688-9697
Practice Address - Country:US
Practice Address - Phone:707-678-5614
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health