Provider Demographics
NPI:1972776292
Name:NICHOLS, JESSICA L (MS, CCC-A)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:L
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:MS, CCC-A
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:L
Other - Last Name:BARR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2022 KELLE DR
Mailing Address - Street 2:
Mailing Address - City:CHESTERTON
Mailing Address - State:IN
Mailing Address - Zip Code:46304-8708
Mailing Address - Country:US
Mailing Address - Phone:219-364-4004
Mailing Address - Fax:219-326-2584
Practice Address - Street 1:304 DETROIT ST
Practice Address - Street 2:
Practice Address - City:LA PORTE
Practice Address - State:IN
Practice Address - Zip Code:46350-2497
Practice Address - Country:US
Practice Address - Phone:219-325-3770
Practice Address - Fax:219-325-8181
Is Sole Proprietor?:No
Enumeration Date:2008-04-08
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN23002292A231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000770974OtherANTHEM
IN200387170Medicaid
IN200387170Medicaid