Healthcare Provider Details

I. General information

NPI: 1275848525
Provider Name (Legal Business Name): JESSICA L NICHOLSON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2010
Last Update Date: 01/06/2021
Certification Date: 01/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1633 N CAPITOL AVE. SUITE 750
INDIANAPOLIS IN
46202-1270
US

IV. Provider business mailing address

250 N SHADELAND AVE
INDIANAPOLIS IN
46219-4959
US

V. Phone/Fax

Practice location:
  • Phone: 317-962-0963
  • Fax: 317-962-2455
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number7100332A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number71003324A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: