Provider Demographics
NPI:1841000619
Name:NICHOLSON, JAQUAN TAYLOR
Entity type:Individual
Prefix:
First Name:JAQUAN
Middle Name:TAYLOR
Last Name:NICHOLSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:691 CHINA BASIN ST APT 347
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94158-2571
Mailing Address - Country:US
Mailing Address - Phone:415-808-9995
Mailing Address - Fax:
Practice Address - Street 1:1318 GATEVIEW AVE
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94130
Practice Address - Country:US
Practice Address - Phone:415-967-5334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-13
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker