Provider Demographics
NPI:1649558479
Name:NICHOLSON, JILL CAROLYN (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:JILL
Middle Name:CAROLYN
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:MISS
Other - First Name:JILL
Other - Middle Name:CAROLYN
Other - Last Name:SEGNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 1200
Mailing Address - Street 2:
Mailing Address - City:PLEASANT GROVE
Mailing Address - State:UT
Mailing Address - Zip Code:84062-1200
Mailing Address - Country:US
Mailing Address - Phone:800-640-3451
Mailing Address - Fax:
Practice Address - Street 1:12176 S 1000 E STE 4
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-3221
Practice Address - Country:US
Practice Address - Phone:800-640-3451
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-27
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID76917363L00000X
WAAP30005742363LF0000X
UT12495745-4405363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily