Provider Demographics
NPI:1891188892
Name:NICHOLS, JESSE (DO)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:NICHOLS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 LOW ST
Mailing Address - Street 2:
Mailing Address - City:BUTTE
Mailing Address - State:MT
Mailing Address - Zip Code:59701-7633
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:633D MEDICAL GROUP/SGHC
Practice Address - Street 2:77 NEALY AVE
Practice Address - City:JOINT BASE LANGLEY-EUSTIS
Practice Address - State:VA
Practice Address - Zip Code:23665-2040
Practice Address - Country:US
Practice Address - Phone:757-764-6800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-15
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102205683207P00000X
390200000X
OH34.012968207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program