Provider Demographics
NPI:1346812575
Name:NICHOLS, JENNA (RBT)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17390 DUGDALE DR STE 100
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46635-1512
Mailing Address - Country:US
Mailing Address - Phone:574-400-2169
Mailing Address - Fax:317-520-8200
Practice Address - Street 1:17390 DUGDALE DR STE 100
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46635-1512
Practice Address - Country:US
Practice Address - Phone:574-400-2169
Practice Address - Fax:317-520-8200
Is Sole Proprietor?:No
Enumeration Date:2021-07-16
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIRBT-21-176075106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician