Provider Demographics
NPI:1386842763
Name:NICHOLS, JEROME TAK (MD)
Entity Type:Individual
Prefix:DR
First Name:JEROME
Middle Name:TAK
Last Name:NICHOLS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 S JEFFERSON ST STE 1006
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24011-1713
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2331 FRANKLIN RD SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24014-1111
Practice Address - Country:US
Practice Address - Phone:540-510-6200
Practice Address - Fax:540-857-5306
Is Sole Proprietor?:No
Enumeration Date:2007-07-06
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA070145207QS0010X
KYTP934208100000X
VA0101261482208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine