Provider Demographics
NPI:1609921667
Name:NIKSCH, JASON
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:NIKSCH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 ALAMEDA DE LAS PULGAS
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94403-1222
Mailing Address - Country:US
Mailing Address - Phone:650-573-3571
Mailing Address - Fax:
Practice Address - Street 1:1950 ALAMEDA DE LAS PULGAS
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94403-1222
Practice Address - Country:US
Practice Address - Phone:650-573-3571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA740192084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A740190Medicaid
CAH54603Medicare UPIN
CA00A740191Medicare PIN
CA00A740190Medicaid