Provider Demographics
NPI:1821752494
Name:NICHOLS, JACQUELINE MARIE
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:MARIE
Last Name:NICHOLS
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 1:506 E HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT PROSPECT
Mailing Address - State:IL
Mailing Address - Zip Code:60056-2138
Mailing Address - Country:US
Mailing Address - Phone:847-807-9116
Mailing Address - Fax:
Practice Address - Street 1:130 S MAIN ST # 1
Practice Address - Street 2:
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148-2670
Practice Address - Country:US
Practice Address - Phone:630-527-3645
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-28
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.024109363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily