Provider Demographics
NPI:1245428812
Name:NICHOLS, JESSICA (OT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:906 TETBURY PL
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39047-9274
Mailing Address - Country:US
Mailing Address - Phone:662-820-8732
Mailing Address - Fax:
Practice Address - Street 1:906 TETBURY PL
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39047-9274
Practice Address - Country:US
Practice Address - Phone:662-820-8732
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-09
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOT1648225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07728286Medicaid