Provider Demographics
NPI:1669795753
Name:NICHOLSON, JILLIAN FRANCES (ATC, LAT)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:FRANCES
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6119 CTH Y # 13
Mailing Address - Street 2:
Mailing Address - City:HAZELHURST
Mailing Address - State:WI
Mailing Address - Zip Code:54531-9762
Mailing Address - Country:US
Mailing Address - Phone:715-564-4326
Mailing Address - Fax:
Practice Address - Street 1:6119 CTH Y # 13
Practice Address - Street 2:
Practice Address - City:HAZELHURST
Practice Address - State:WI
Practice Address - Zip Code:54531-9762
Practice Address - Country:US
Practice Address - Phone:715-564-4326
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-04
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1059-0392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1059-039OtherWI STATE LICENSURE
2000000365OtherBOC CERTIFICATION NUMBER