Provider Demographics
NPI:1831748318
Name:NICHOLSON, JACK LEE I
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:LEE
Last Name:NICHOLSON
Suffix:I
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:460 AZTEC LN
Mailing Address - Street 2:
Mailing Address - City:LATHROP
Mailing Address - State:CA
Mailing Address - Zip Code:95330-9142
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:460 AZTEC LN
Practice Address - Street 2:
Practice Address - City:LATHROP
Practice Address - State:CA
Practice Address - Zip Code:95330-9142
Practice Address - Country:US
Practice Address - Phone:209-451-8732
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-08
Last Update Date:2019-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3747A0650X
CA3747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1933200000XMedicaid
CA3747A0650XMedicaid
CA193200000XMedicaid