Provider Demographics
NPI:1295627727
Name:MEDINA, NICHOLAS JACOB (BS)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:JACOB
Last Name:MEDINA
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:NICK
Other - Middle Name:JACOB
Other - Last Name:MEDINA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1216 ARCH ST FL 6
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-2835
Mailing Address - Country:US
Mailing Address - Phone:215-981-0088
Mailing Address - Fax:
Practice Address - Street 1:1216 ARCH ST FL 6
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-2835
Practice Address - Country:US
Practice Address - Phone:215-981-0088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-18
Last Update Date:2025-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No104100000XBehavioral Health & Social Service ProvidersSocial Worker