Provider Demographics
NPI:1811067788
Name:NICHOLAS, JEAN M (OTR)
Entity type:Individual
Prefix:
First Name:JEAN
Middle Name:M
Last Name:NICHOLAS
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO332
Mailing Address - Street 2:
Mailing Address - City:HAGAMAN
Mailing Address - State:NY
Mailing Address - Zip Code:12086
Mailing Address - Country:US
Mailing Address - Phone:518-842-2468
Mailing Address - Fax:
Practice Address - Street 1:43 LIBERTY DR
Practice Address - Street 2:
Practice Address - City:AMSTERDAM
Practice Address - State:NY
Practice Address - Zip Code:12010-5635
Practice Address - Country:US
Practice Address - Phone:518-954-2058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006858-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist