Provider Demographics
NPI:1467617126
Name:NICHOLAS, JENNIFER LYNN (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:LYNN
Last Name:NICHOLAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 BURNET AVE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45229-3019
Mailing Address - Country:US
Mailing Address - Phone:513-245-3613
Mailing Address - Fax:513-585-5511
Practice Address - Street 1:3188 BELLEVUE AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-2364
Practice Address - Country:US
Practice Address - Phone:513-584-4391
Practice Address - Fax:513-584-0431
Is Sole Proprietor?:No
Enumeration Date:2008-07-22
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY572892085P0229X
MO20160259022085P0229X
OH35.0931452085R0202X, 2085P0229X
IL036-1187412085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Yes2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILENROLLEDMedicaid
MO1467617126Medicaid
OH7100517530Medicaid