Healthcare Provider Details

I. General information

NPI: 1932620895
Provider Name (Legal Business Name): JENNIFER LYNN NICKOL D.O
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2017
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 SW ARCHER RD
GAINESVILLE FL
32608-1134
US

IV. Provider business mailing address

PO BOX 100288
GAINESVILLE FL
32610-0277
US

V. Phone/Fax

Practice location:
  • Phone: 352-265-9928
  • Fax:
Mailing address:
  • Phone: 352-273-9079
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberOS16938
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207RA0001X
TaxonomyAdvanced Heart Failure and Transplant Cardiology Physician
License NumberOS23686
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: