Provider Demographics
NPI:1679124739
Name:NICHOLS, JODY
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:
Last Name:NICHOLS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:806 CARTER ST
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:LA
Mailing Address - Zip Code:71373-3206
Mailing Address - Country:US
Mailing Address - Phone:318-734-0034
Mailing Address - Fax:601-493-5898
Practice Address - Street 1:806 CARTER ST
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:LA
Practice Address - Zip Code:71373-3206
Practice Address - Country:US
Practice Address - Phone:318-734-0034
Practice Address - Fax:601-493-5898
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-20
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LACIT-5033101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5033OtherSTATE OF LOUISIANA ADDICTIVE DISORDER REGULATORY AUTHORITY