Provider Demographics
NPI:1407190739
Name:NICHOLSON, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 OAKWOOD BLVD STE 130
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33020-1937
Mailing Address - Country:US
Mailing Address - Phone:954-736-0278
Mailing Address - Fax:
Practice Address - Street 1:1 OAKWOOD BLVD STE 130
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33020-1937
Practice Address - Country:US
Practice Address - Phone:954-736-0278
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-27
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCOTA/L 12341224Z00000X
FLSZ9078235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant