Provider Demographics
NPI:1699057331
Name:NICKELL, JERRAD (DO)
Entity type:Individual
Prefix:DR
First Name:JERRAD
Middle Name:
Last Name:NICKELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1340 HAL GREER BLVD
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-3804
Mailing Address - Country:US
Mailing Address - Phone:304-526-2200
Mailing Address - Fax:304-399-1507
Practice Address - Street 1:1340 HAL GREER BLVD
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-3804
Practice Address - Country:US
Practice Address - Phone:304-526-2200
Practice Address - Fax:304-399-1507
Is Sole Proprietor?:No
Enumeration Date:2011-09-19
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34010890207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0089986Medicaid
KY7100258330Medicaid
WV1699057331Medicaid