Healthcare Provider Details

I. General information

NPI: 1134032063
Provider Name (Legal Business Name): JENNIFER M NICHOLSON RN, BSN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2026
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9907 OAK HAVEN DR
SHREVEPORT LA
71106-8223
US

IV. Provider business mailing address

9907 OAK HAVEN DR
SHREVEPORT LA
71106-8223
US

V. Phone/Fax

Practice location:
  • Phone: 318-349-8180
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WX0200X
TaxonomyOncology Registered Nurse
License NumberRN078936
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: