Provider Demographics
NPI:1528473824
Name:NICHOLSON, JENNIFER (AGNP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:AGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 CARTER PARK DR STE 3A
Mailing Address - Street 2:
Mailing Address - City:SENECA
Mailing Address - State:SC
Mailing Address - Zip Code:29678-1152
Mailing Address - Country:US
Mailing Address - Phone:864-885-0058
Mailing Address - Fax:864-640-4400
Practice Address - Street 1:109 CARTER PARK DR STE 3A
Practice Address - Street 2:
Practice Address - City:SENECA
Practice Address - State:SC
Practice Address - Zip Code:29678-1152
Practice Address - Country:US
Practice Address - Phone:864-885-0058
Practice Address - Fax:864-885-0098
Is Sole Proprietor?:No
Enumeration Date:2014-06-25
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC18813363LA2200X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health