Provider Demographics
NPI:1528007036
Name:NICHOLS, JACK CLIFFORD II (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:CLIFFORD
Last Name:NICHOLS
Suffix:II
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 848914
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02284-8914
Mailing Address - Country:US
Mailing Address - Phone:530-246-2430
Mailing Address - Fax:530-246-1907
Practice Address - Street 1:1230 EAST ST
Practice Address - Street 2:SUITE A
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-0821
Practice Address - Country:US
Practice Address - Phone:530-246-2430
Practice Address - Fax:530-246-1907
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG35731207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0216660001Medicare NSC
CA00G357310Medicare PIN
CAA89605Medicare UPIN