Provider Demographics
NPI:1023500519
Name:NICHOLS, JAKLYNN DENISE (RBT-18-56780)
Entity type:Individual
Prefix:
First Name:JAKLYNN
Middle Name:DENISE
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:RBT-18-56780
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:933 LOUISE AVE STE 10119
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204-0053
Mailing Address - Country:US
Mailing Address - Phone:773-997-0773
Mailing Address - Fax:
Practice Address - Street 1:500 FAIRWAY DR STE 102
Practice Address - Street 2:
Practice Address - City:DEERFIELD BEACH
Practice Address - State:FL
Practice Address - Zip Code:33441-1817
Practice Address - Country:US
Practice Address - Phone:877-418-2978
Practice Address - Fax:866-500-2186
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-31
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA18-56780106S00000X
IL18-56780106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician