Provider Demographics
NPI:1275870339
Name:NICKENS, JESSICA GRAVETTE (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:GRAVETTE
Last Name:NICKENS
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7830 HIGHWAY 72 W
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:AL
Mailing Address - Zip Code:35758-9500
Mailing Address - Country:US
Mailing Address - Phone:256-864-0511
Mailing Address - Fax:256-864-0533
Practice Address - Street 1:7830 HIGHWAY 72 W
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35758-9500
Practice Address - Country:US
Practice Address - Phone:256-864-0511
Practice Address - Fax:256-864-0533
Is Sole Proprietor?:No
Enumeration Date:2013-01-09
Last Update Date:2013-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL15371183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist