Provider Demographics
NPI:1609188093
Name:DR. JOURDAN NICHOLLS, DPM, INC.
Entity Type:Organization
Organization Name:DR. JOURDAN NICHOLLS, DPM, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JOURDAN
Authorized Official - Middle Name:CLIVE
Authorized Official - Last Name:NICHOLLS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:509-582-2057
Mailing Address - Street 1:7103 W GRANDRIDGE BLVD
Mailing Address - Street 2:SUITE F
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-6713
Mailing Address - Country:US
Mailing Address - Phone:509-582-2057
Mailing Address - Fax:509-374-4945
Practice Address - Street 1:7103 W GRANDRIDGE BLVD
Practice Address - Street 2:SUITE F
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-6713
Practice Address - Country:US
Practice Address - Phone:509-582-2057
Practice Address - Fax:509-374-4945
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-14
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPO 549213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1101377Medicaid
WAU58084Medicare UPIN
WAAB00833Medicare PIN