Basic Information
| Provider Information | |||||||||
| NPI: | 1780041210 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NICHOLS | ||||||||
| FirstName: | JEAN | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3441 SPRUCE ST | ||||||||
| Address2: | |||||||||
| City: | NORTH BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974591129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412171514 | ||||||||
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| Practice Location | |||||||||
| Address1: | 400 VIRGINIA AVE | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | NORTH BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974593477 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417510357 | ||||||||
| FaxNumber: | 5417519985 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2016 | ||||||||
| LastUpdateDate: | 01/28/2016 | ||||||||
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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 | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.