Healthcare Provider Details

I. General information

NPI: 1891188892
Provider Name (Legal Business Name): JESSE NICHOLS DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2015
Last Update Date: 07/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

633D MEDICAL GROUP/SGHC 77 NEALY AVE
JOINT BASE LANGLEY-EUSTIS VA
23665-2040
US

IV. Provider business mailing address

112 LOW ST
BUTTE MT
59701-7633
US

V. Phone/Fax

Practice location:
  • Phone: 757-764-6800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number0102205683
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number34.012968
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: