Provider Demographics
NPI:1831683671
Name:NICHOLS, JENNY
Entity type:Individual
Prefix:
First Name:JENNY
Middle Name:
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 238
Mailing Address - Street 2:
Mailing Address - City:BETHLEHEM
Mailing Address - State:CT
Mailing Address - Zip Code:06751-0238
Mailing Address - Country:US
Mailing Address - Phone:203-266-5149
Mailing Address - Fax:
Practice Address - Street 1:25 STATE ROUTE 39
Practice Address - Street 2:
Practice Address - City:NEW FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06812-4044
Practice Address - Country:US
Practice Address - Phone:203-312-9818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-15
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT6272183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist