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General NPI Number Information
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NPI Number | 1922418169
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Entity Type | Individual
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Provider Name | JACQUELYN MARIE NICKELE
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Gender | Female
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Dates
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Enumeration Date | 04/28/2014
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Last Update Date | 05/31/2017
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Provider Practice Location Address
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Address Line | 1815 BARDSTOWN RD
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City | LOUISVILLE
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State | KY
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Zip | 40205-1433
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Country | US
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Telephone | 502-459-4120
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 860036
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City | MINNEAPOLIS
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State | MN
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Zip | 55486-0036
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Country | US
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Telephone | 502-459-4120
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 9476
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License Number State | KY
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Taxonomy #2
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 12012676A
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License Number State | IN
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Taxonomy #3
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 9476
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License Number State | KY
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