Healthcare Provider Details

I. General information

NPI: 1972776292
Provider Name (Legal Business Name): JESSICA L NICHOLS MS, CCC-A
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA L BARR

II. Dates (important events)

Enumeration Date: 04/08/2008
Last Update Date: 09/21/2020
Certification Date: 09/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 DETROIT ST
LA PORTE IN
46350-2497
US

IV. Provider business mailing address

2022 KELLE DR
CHESTERTON IN
46304-8708
US

V. Phone/Fax

Practice location:
  • Phone: 219-325-3770
  • Fax: 219-325-8181
Mailing address:
  • Phone: 219-364-4004
  • Fax: 219-326-2584

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number23002292A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: