Provider Demographics
NPI:1588804736
Name:NICHOLSON, JANE ALICE (PHD)
Entity Type:Individual
Prefix:DR
First Name:JANE
Middle Name:ALICE
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 4TH ST NE
Mailing Address - Street 2:
Mailing Address - City:PRIMGHAR
Mailing Address - State:IA
Mailing Address - Zip Code:51245-1004
Mailing Address - Country:US
Mailing Address - Phone:712-630-1243
Mailing Address - Fax:
Practice Address - Street 1:255 4TH ST NE
Practice Address - Street 2:
Practice Address - City:PRIMGHAR
Practice Address - State:IA
Practice Address - Zip Code:51245-1004
Practice Address - Country:US
Practice Address - Phone:712-630-1243
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-01
Last Update Date:2009-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001103103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA087059535038Medicaid
VA087059535038Medicaid