Provider Demographics
NPI:1922476886
Name:JIMMI, NICHOLE
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:
Last Name:JIMMI
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 1:1670 KETTNER BLVD
Mailing Address - Street 2:APT 122
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-2522
Mailing Address - Country:US
Mailing Address - Phone:561-674-4994
Mailing Address - Fax:
Practice Address - Street 1:1670 KETTNER BLVD
Practice Address - Street 2:APT 122
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-2522
Practice Address - Country:US
Practice Address - Phone:561-674-4994
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-09
Last Update Date:2015-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95061156163WP0809X, 283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
No283Q00000XHospitalsPsychiatric Hospital