Provider Demographics
NPI:1588931877
Name:NICKERSON, JEFFRIES GEORGE (CHA 3)
Entity type:Individual
Prefix:
First Name:JEFFRIES
Middle Name:GEORGE
Last Name:NICKERSON
Suffix:
Gender:M
Credentials:CHA 3
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 188
Mailing Address - Street 2:
Mailing Address - City:KLAWOCK
Mailing Address - State:AK
Mailing Address - Zip Code:99925-0188
Mailing Address - Country:US
Mailing Address - Phone:907-755-4800
Mailing Address - Fax:907-755-4981
Practice Address - Street 1:7300 KLAWOCK-HOLLIS
Practice Address - Street 2:
Practice Address - City:KLAWOCK
Practice Address - State:AK
Practice Address - Zip Code:99921
Practice Address - Country:US
Practice Address - Phone:907-755-4800
Practice Address - Fax:907-755-4981
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-30
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146M00000XEmergency Medical Service ProvidersEmergency Medical Technician, Intermediate