Provider Demographics
NPI:1467013698
Name:NICHOLSON, JAKE ANTHONY (DO)
Entity Type:Individual
Prefix:
First Name:JAKE
Middle Name:ANTHONY
Last Name:NICHOLSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4069 LAKE DR SE STE 312
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-8816
Mailing Address - Country:US
Mailing Address - Phone:616-267-8700
Mailing Address - Fax:616-267-8247
Practice Address - Street 1:100 MICHIGAN ST NE STE A501
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2560
Practice Address - Country:US
Practice Address - Phone:616-391-0056
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-27
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI51510140432086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery