Provider Demographics
NPI:1669960076
Name:JAEGER, NICKO MICHELLE (FNP-BC)
Entity type:Individual
Prefix:MS
First Name:NICKO
Middle Name:MICHELLE
Last Name:JAEGER
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 IRON BARK
Mailing Address - Street 2:
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656-2169
Mailing Address - Country:US
Mailing Address - Phone:310-351-0789
Mailing Address - Fax:
Practice Address - Street 1:30 IRON BARK
Practice Address - Street 2:
Practice Address - City:ALISO VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92656-2169
Practice Address - Country:US
Practice Address - Phone:310-351-0789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-01
Last Update Date:2018-08-08
Deactivation Date:2018-06-05
Deactivation Code:
Reactivation Date:2018-08-08
Provider Licenses
StateLicense IDTaxonomies
CA524428NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily