Provider Demographics
NPI:1629150750
Name:NOLLE, JACKIE JEAN JACQUES (D C)
Entity Type:Individual
Prefix:DR
First Name:JACKIE
Middle Name:JEAN JACQUES
Last Name:NOLLE
Suffix:
Gender:M
Credentials:D C
Other - Prefix:DR
Other - First Name:JACK
Other - Middle Name:J
Other - Last Name:NOLLE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:D C
Mailing Address - Street 1:9476 DOUBLE R BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89521-6022
Mailing Address - Country:US
Mailing Address - Phone:775-284-3333
Mailing Address - Fax:775-284-3395
Practice Address - Street 1:9476 DOUBLE R BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89521-6022
Practice Address - Country:US
Practice Address - Phone:775-284-3333
Practice Address - Fax:775-284-3395
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVB897111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVU84495Medicare UPIN
NV36847Medicare ID - Type Unspecified