Provider Demographics
NPI:1124448220
Name:JIRIK, NICOLE (LMT, LE)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:JIRIK
Suffix:
Gender:F
Credentials:LMT, LE
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 445
Mailing Address - Street 2:
Mailing Address - City:FOLLY BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29439-0445
Mailing Address - Country:US
Mailing Address - Phone:843-588-5551
Mailing Address - Fax:
Practice Address - Street 1:83 CENTER STREET
Practice Address - Street 2:SUITE B
Practice Address - City:FOLLY BEACH
Practice Address - State:SC
Practice Address - Zip Code:29439
Practice Address - Country:US
Practice Address - Phone:843-588-5551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-16
Last Update Date:2016-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCMAS9039225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist