Healthcare Provider Details

I. General information

NPI: 1629563002
Provider Name (Legal Business Name): JEANA NICHOLS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JEANA BAKER

II. Dates (important events)

Enumeration Date: 06/27/2018
Last Update Date: 08/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 N RIVERPOINT BLVD STE 245
SPOKANE WA
99202-1649
US

IV. Provider business mailing address

203 N WASHINGTON ST STE 300
SPOKANE WA
99201-0254
US

V. Phone/Fax

Practice location:
  • Phone: 509-232-8138
  • Fax:
Mailing address:
  • Phone: 509-444-8888
  • Fax: 509-444-7806

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH60675114
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: