Healthcare Provider Details

I. General information

NPI: 1740311786
Provider Name (Legal Business Name): JERILYNN NICHOLS MS, PHARMD, CGC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 01/20/2022
Certification Date: 01/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4820 S CLARK ST
MEXICO MO
65265-4111
US

IV. Provider business mailing address

4820 S CLARK ST
MEXICO MO
65265-4111
US

V. Phone/Fax

Practice location:
  • Phone: 573-239-5715
  • Fax:
Mailing address:
  • Phone: 573-581-2600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2015023146
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code170300000X
TaxonomyGenetic Counselor (M.S.)
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: