Provider Demographics
NPI:1538701743
Name:NICHOLS, JACQUELINE S (MS, BCBA, LABA)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:S
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:MS, BCBA, LABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345A GREENWOOD ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01607-1753
Mailing Address - Country:US
Mailing Address - Phone:508-363-0200
Mailing Address - Fax:
Practice Address - Street 1:345A GREENWOOD ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01607-1753
Practice Address - Country:US
Practice Address - Phone:508-363-0200
Practice Address - Fax:508-363-1213
Is Sole Proprietor?:No
Enumeration Date:2019-10-09
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2795-MH-B1222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist