Provider Demographics
NPI:1790028801
Name:NICHOLS, JENNIFER LAUREN (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LAUREN
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 1:25 N WINFIELD RD STE 432
Mailing Address - Street 2:
Mailing Address - City:WINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60190-1222
Mailing Address - Country:US
Mailing Address - Phone:630-933-4056
Mailing Address - Fax:
Practice Address - Street 1:25 N WINFIELD RD STE 432
Practice Address - Street 2:
Practice Address - City:WINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60190-1222
Practice Address - Country:US
Practice Address - Phone:630-933-4056
Practice Address - Fax:630-933-4057
Is Sole Proprietor?:No
Enumeration Date:2013-03-27
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD1817912084N0400X
IL0361490102084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology