Provider Demographics
NPI:1437217791
Name:NICHOLS, JODY (LCSW)
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:
Last Name:NICHOLS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9601 LILE DR
Mailing Address - Street 2:SUITE 1050
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-6321
Mailing Address - Country:US
Mailing Address - Phone:501-228-7400
Mailing Address - Fax:501-537-7412
Practice Address - Street 1:9601 LILE DR
Practice Address - Street 2:SUITE 1050
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-6321
Practice Address - Country:US
Practice Address - Phone:501-228-7400
Practice Address - Fax:501-537-7412
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC5421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5S116Medicare ID - Type Unspecified