Provider Demographics
NPI:1619223591
Name:JAZO, NICOLE ASHLEY
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ASHLEY
Last Name:JAZO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1109
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-7109
Mailing Address - Country:US
Mailing Address - Phone:815-766-3024
Mailing Address - Fax:815-756-2944
Practice Address - Street 1:760 FOXPOINTE DR
Practice Address - Street 2:
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178-3221
Practice Address - Country:US
Practice Address - Phone:815-748-8334
Practice Address - Fax:815-748-8921
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-30
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490200961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical