Provider Demographics
NPI:1215481999
Name:NICOLAY, JACIE
Entity type:Individual
Prefix:
First Name:JACIE
Middle Name:
Last Name:NICOLAY
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 1:701 S BEECHTREE ST
Mailing Address - Street 2:
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417-2336
Mailing Address - Country:US
Mailing Address - Phone:231-884-6771
Mailing Address - Fax:
Practice Address - Street 1:701 S BEECHTREE ST
Practice Address - Street 2:
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-2336
Practice Address - Country:US
Practice Address - Phone:231-884-6771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-10
Last Update Date:2016-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other