Provider Demographics
NPI:1528332921
Name:NICHOLS, JASEN RALPH (MA)
Entity type:Individual
Prefix:MR
First Name:JASEN
Middle Name:RALPH
Last Name:NICHOLS
Suffix:
Gender:M
Credentials:MA
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 609
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:WV
Mailing Address - Zip Code:26143-0609
Mailing Address - Country:US
Mailing Address - Phone:304-275-3301
Mailing Address - Fax:304-275-4798
Practice Address - Street 1:483 COURT STREET
Practice Address - Street 2:
Practice Address - City:ELIZABETH
Practice Address - State:WV
Practice Address - Zip Code:26143-0609
Practice Address - Country:US
Practice Address - Phone:304-275-3301
Practice Address - Fax:304-275-4798
Is Sole Proprietor?:No
Enumeration Date:2012-03-02
Last Update Date:2017-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1011103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical