Provider Demographics
NPI:1639639685
Name:NICHOLS, JACQUELINE WYNNE (MD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:WYNNE
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 LAKESIDE DR STE 209
Mailing Address - Street 2:
Mailing Address - City:BANNOCKBURN
Mailing Address - State:IL
Mailing Address - Zip Code:60015-1200
Mailing Address - Country:US
Mailing Address - Phone:847-562-1410
Mailing Address - Fax:847-929-4605
Practice Address - Street 1:1000 CENTRAL ST STE 700
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-1769
Practice Address - Country:US
Practice Address - Phone:847-869-3300
Practice Address - Fax:847-869-1303
Is Sole Proprietor?:No
Enumeration Date:2019-03-24
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL036166140207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program