MEDICARE: JESSICA ANN NICHOLS LMT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	195006	OK

General Provider Information

NPI Number	:	1619832110
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA ANN NICHOLS LMT

Provider Business Mailing Address
First Line	:	2401 W OMAHA ST APT 2524
Second Line	:
City	:	BROKEN ARROW
State	:	OK
Zip	:	74012-0656
Country	:	US
Telephone Number	:	918-812-0527
Fax Number	:

Provider Business Practice Location Address
First Line	:	6321 E 102ND ST
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74137-7044
Country	:	US
Telephone Number	:	918-884-7571
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/17/2025
Last Update Date	:	12/17/2025

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