1083987143 NPI number — JESSI ELIZABETH NICHOLSON L.AC. MOM

Table of content: JESSI ELIZABETH NICHOLSON L.AC. MOM (NPI 1083987143)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083987143 NPI number — JESSI ELIZABETH NICHOLSON L.AC. MOM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NICHOLSON
Provider First Name:
JESSI
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
L.AC. MOM
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083987143
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/20/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 853
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND MARAIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55604
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-370-8378
Provider Business Mailing Address Fax Number:
218-387-3584

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 W HWY 61
Provider Second Line Business Practice Location Address:
SUITE 130
Provider Business Practice Location Address City Name:
GRAND MARAIS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55604
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-370-8378
Provider Business Practice Location Address Fax Number:
218-387-3584
Provider Enumeration Date:
02/20/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 171100000X , with the licence number:  1451 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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