MEDICARE: JENNIFER NICHOLS CCC-SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	1234	ND
2	235Z00000X	Speech-Language Pathologist	111513	TX

General Provider Information

NPI Number	:	1639505993
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER NICHOLS CCC-SLP

Provider Business Mailing Address
First Line	:	1000 SAINT LOUIS AVE STE 102
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-3377
Country	:	US
Telephone Number	:	817-921-5020
Fax Number	:	817-921-5022

Provider Business Practice Location Address
First Line	:	1000 SAINT LOUIS AVE STE 102
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-3377
Country	:	US
Telephone Number	:	817-921-5020
Fax Number	:	817-921-5022

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/18/2013
Last Update Date	:	07/21/2022

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Directions to “ JENNIFER NICHOLS CCC-SLP” Practice Location

Language	Start Address	Practice Location

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