Healthcare Provider Details

I. General information

NPI: 1871120469
Provider Name (Legal Business Name): JENNA NICCOLLS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2020
Last Update Date: 09/11/2025
Certification Date: 09/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2515 CYCLONE DR STE B
WATERLOO IA
50701-9715
US

IV. Provider business mailing address

2515 CYCLONE DR STE B
WATERLOO IA
50701-9715
US

V. Phone/Fax

Practice location:
  • Phone: 319-888-8044
  • Fax: 319-349-8402
Mailing address:
  • Phone: 319-888-8044
  • Fax: 319-349-8402

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number105061
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: