Provider Demographics
NPI:1902146764
Name:NICHOLS, JEFFERSON JR (LBSW)
Entity Type:Individual
Prefix:MR
First Name:JEFFERSON
Middle Name:
Last Name:NICHOLS
Suffix:JR
Gender:M
Credentials:LBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24354 ECORSE RD
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:MI
Mailing Address - Zip Code:48180-1643
Mailing Address - Country:US
Mailing Address - Phone:313-292-5300
Mailing Address - Fax:
Practice Address - Street 1:24354 ECORSE RD
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:MI
Practice Address - Zip Code:48180-1643
Practice Address - Country:US
Practice Address - Phone:313-292-5300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-15
Last Update Date:2013-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802084389104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker