Provider Demographics
NPI:1316516412
Name:NICHOLS, JESSAMYN (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:JESSAMYN
Middle Name:
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 E BREMER AVE
Mailing Address - Street 2:
Mailing Address - City:WAVERLY
Mailing Address - State:IA
Mailing Address - Zip Code:50677-3435
Mailing Address - Country:US
Mailing Address - Phone:319-352-4544
Mailing Address - Fax:
Practice Address - Street 1:217 E BREMER AVE
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:IA
Practice Address - Zip Code:50677-3435
Practice Address - Country:US
Practice Address - Phone:319-352-4544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-22
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA085663235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA665992Medicaid