Provider Demographics
NPI:1417686189
Name:MAIN, JESSICA NICHOLS (PHARMD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:NICHOLS
Last Name:MAIN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:ROSE
Other - Last Name:NICHOLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:2631 E ECLIPSE AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-4625
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:785 N MEDICAL CENTER DR W
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93611-6878
Practice Address - Country:US
Practice Address - Phone:559-387-1862
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-08
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA81345183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist