Provider Demographics
NPI:1982684601
Name:NICHOLS, JORDAN
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:NICHOLS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 N NORTHWEST HWY
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-3341
Mailing Address - Country:US
Mailing Address - Phone:847-823-5077
Mailing Address - Fax:847-823-0371
Practice Address - Street 1:135 N NORTHWEST HWY
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-3341
Practice Address - Country:US
Practice Address - Phone:847-823-5077
Practice Address - Fax:847-823-0371
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-19
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0160003281213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T37817Medicare UPIN
IL5023100001Medicare NSC
IL683700Medicare PIN