Healthcare Provider Details

I. General information

NPI: 1326645417
Provider Name (Legal Business Name): JENNIFER M NICKELL FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2020
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2485 12TH ST SE
SALEM OR
97302-2151
US

IV. Provider business mailing address

30494 SW RUTH ST
WILSONVILLE OR
97070-8692
US

V. Phone/Fax

Practice location:
  • Phone: 503-363-8047
  • Fax: 503-363-6571
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number202010122NP-PP
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number200040937RN
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: