Provider Demographics
NPI:1174901946
Name:NICOSON, JEANNA (RN)
Entity type:Individual
Prefix:
First Name:JEANNA
Middle Name:
Last Name:NICOSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:JEANNA
Other - Middle Name:
Other - Last Name:BOLMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:24934 FIR GROVE LN
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:OR
Mailing Address - Zip Code:97437-9751
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24934 FIR GROVE LN
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:OR
Practice Address - Zip Code:97437-9751
Practice Address - Country:US
Practice Address - Phone:541-234-3255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-13
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201242522RN163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR201242522RNOtherOSBN