Provider Demographics
NPI:1629056635
Name:NICHOLS, JENNIE ELIZABETH (DDS)
Entity Type:Individual
Prefix:DR
First Name:JENNIE
Middle Name:ELIZABETH
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:243 S BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-2601
Mailing Address - Country:US
Mailing Address - Phone:330-725-4101
Mailing Address - Fax:
Practice Address - Street 1:243 S BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-2601
Practice Address - Country:US
Practice Address - Phone:330-725-4101
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH300218131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice