Provider Demographics
NPI:1356612915
Name:NICHOLAS, JENNIFER MARIE (CADC II)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:MARIE
Last Name:NICHOLAS
Suffix:
Gender:F
Credentials:CADC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 13219
Mailing Address - Street 2:
Mailing Address - City:COYOTE
Mailing Address - State:CA
Mailing Address - Zip Code:95013-3219
Mailing Address - Country:US
Mailing Address - Phone:408-281-8555
Mailing Address - Fax:408-281-6580
Practice Address - Street 1:9500 MALECH ROAD
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95138
Practice Address - Country:US
Practice Address - Phone:408-281-8555
Practice Address - Fax:408-281-6580
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-13
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA94-1688522101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)