Provider Demographics
NPI:1316694169
Name:NICOLAS, JESSIE
Entity type:Individual
Prefix:
First Name:JESSIE
Middle Name:
Last Name:NICOLAS
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 1:6 GEORGE RD
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:MA
Mailing Address - Zip Code:02343-1267
Mailing Address - Country:US
Mailing Address - Phone:617-750-4477
Mailing Address - Fax:
Practice Address - Street 1:6 GEORGE RD
Practice Address - Street 2:
Practice Address - City:HOLBROOK
Practice Address - State:MA
Practice Address - Zip Code:02343-1267
Practice Address - Country:US
Practice Address - Phone:617-750-4477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-02
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1234172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver