Provider Demographics
NPI:1639505993
Name:NICHOLS, JENNIFER (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 SAINT LOUIS AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-3377
Mailing Address - Country:US
Mailing Address - Phone:817-921-5020
Mailing Address - Fax:817-921-5022
Practice Address - Street 1:1000 SAINT LOUIS AVE STE 102
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-3377
Practice Address - Country:US
Practice Address - Phone:817-921-5020
Practice Address - Fax:817-921-5022
Is Sole Proprietor?:No
Enumeration Date:2013-09-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1234235Z00000X
TX111513235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist