Healthcare Provider Details

I. General information

NPI: 1831995893
Provider Name (Legal Business Name): JACQUELINE NICHOLS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/20/2025
Last Update Date: 02/20/2025
Certification Date: 02/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

635 ANDERSON RD STE 10
DAVIS CA
95616-3505
US

IV. Provider business mailing address

1265 WOODVALE DR
DIXON CA
95620-2654
US

V. Phone/Fax

Practice location:
  • Phone: 530-758-1122
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number95033756
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: