Provider Demographics
NPI:1669842571
Name:NICHOLSON, JENNIFER SCOTT
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:SCOTT
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:699 FARMHOUSE LN
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-9402
Mailing Address - Country:US
Mailing Address - Phone:406-556-6500
Mailing Address - Fax:406-588-8361
Practice Address - Street 1:699 FARMHOUSE LN
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-9402
Practice Address - Country:US
Practice Address - Phone:406-556-6500
Practice Address - Fax:406-588-8361
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-05
Last Update Date:2015-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT72169251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health