Provider Demographics
NPI:1780897405
Name:MCNICHOL, JENNIFER SUSAN (MD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:SUSAN
Last Name:MCNICHOL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 TONGASS DR
Mailing Address - Street 2:
Mailing Address - City:SITKA
Mailing Address - State:AK
Mailing Address - Zip Code:99835-9416
Mailing Address - Country:US
Mailing Address - Phone:907-966-2411
Mailing Address - Fax:907-966-8444
Practice Address - Street 1:222 TONGASS DR
Practice Address - Street 2:
Practice Address - City:SITKA
Practice Address - State:AK
Practice Address - Zip Code:99835-9416
Practice Address - Country:US
Practice Address - Phone:907-966-2411
Practice Address - Fax:907-966-8444
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK3716208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD3716Medicaid
AKH02611Medicare UPIN
AK8EB990Medicare PIN
AKMD3716Medicaid
AK8EB992Medicare PIN
AK8EB993Medicare PIN
AK8EB989Medicare ID - Type Unspecified
AK8EB991Medicare PIN