Provider Demographics
NPI:1689655516
Name:NICHOLSON, JILL A (MD)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:A
Last Name:NICHOLSON
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 1:1320 WEST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055
Mailing Address - Country:US
Mailing Address - Phone:220-564-4151
Mailing Address - Fax:220-564-7153
Practice Address - Street 1:420 N JAMES RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43219-1834
Practice Address - Country:US
Practice Address - Phone:614-257-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35077718207Q00000X
OH35.077718207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2252333Medicaid
OHH068302Medicare PIN
OH4171854Medicare PIN
OH2252333Medicaid