Basic Information
| Provider Information | |||||||||
| NPI: | 1639505993 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NICHOLS | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | |||||||||
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| Credential: | CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 SAINT LOUIS AVE STE 102 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761043377 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8179215020 | ||||||||
| FaxNumber: | 8179215022 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 SAINT LOUIS AVE STE 102 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761043377 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8179215020 | ||||||||
| FaxNumber: | 8179215022 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/18/2013 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 1234 | ND | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | 111513 | TX | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.