Provider Demographics
NPI:1306282918
Name:NICHOLSON, JACY ADAM (DDS)
Entity type:Individual
Prefix:
First Name:JACY
Middle Name:ADAM
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3676 W 200S
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:IN
Mailing Address - Zip Code:47546-8200
Mailing Address - Country:US
Mailing Address - Phone:812-661-0024
Mailing Address - Fax:
Practice Address - Street 1:630 KIMMELL RD
Practice Address - Street 2:SUITE C
Practice Address - City:VINCENNES
Practice Address - State:IN
Practice Address - Zip Code:47591-6330
Practice Address - Country:US
Practice Address - Phone:812-316-2013
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-22
Last Update Date:2013-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011947A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice