Provider Demographics
NPI:1518625730
Name:NICKEL, JENNIFER MAE
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MAE
Last Name:NICKEL
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 1:506 E SAN ANTONIO ST
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77901-6060
Mailing Address - Country:US
Mailing Address - Phone:361-484-8438
Mailing Address - Fax:
Practice Address - Street 1:4392 FM 447
Practice Address - Street 2:
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77905-2776
Practice Address - Country:US
Practice Address - Phone:361-484-8438
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-05
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX783433163W00000X
TX1069026363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163W00000XNursing Service ProvidersRegistered Nurse