Provider Demographics
NPI:1740311786
Name:NICHOLS, JERILYNN (MS, PHARMD, CGC)
Entity type:Individual
Prefix:DR
First Name:JERILYNN
Middle Name:
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:MS, PHARMD, CGC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4820 S CLARK ST
Mailing Address - Street 2:
Mailing Address - City:MEXICO
Mailing Address - State:MO
Mailing Address - Zip Code:65265-4111
Mailing Address - Country:US
Mailing Address - Phone:573-581-2600
Mailing Address - Fax:
Practice Address - Street 1:4820 S CLARK ST
Practice Address - Street 2:
Practice Address - City:MEXICO
Practice Address - State:MO
Practice Address - Zip Code:65265-4111
Practice Address - Country:US
Practice Address - Phone:573-239-5715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
170300000X
MO2015023146183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No170300000XOther Service ProvidersGenetic Counselor, MS