Provider Demographics
NPI:1275848525
Name:NICHOLSON, JESSICA L (NP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:L
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1633 N CAPITOL AVE.
Practice Address - Street 2:SUITE 750
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-1270
Practice Address - Country:US
Practice Address - Phone:317-962-0963
Practice Address - Fax:317-962-2455
Is Sole Proprietor?:No
Enumeration Date:2010-08-11
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN7100332A363LA2200X
IN71003324A363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200995570Medicaid
INM400022503Medicare PIN
INM400064967Medicare PIN