Provider Demographics
NPI:1184277550
Name:NICHOLS, JENI LEIGH (LAC)
Entity type:Individual
Prefix:
First Name:JENI
Middle Name:LEIGH
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:471 E MERCURY ST
Mailing Address - Street 2:
Mailing Address - City:BUTTE
Mailing Address - State:MT
Mailing Address - Zip Code:59701-1906
Mailing Address - Country:US
Mailing Address - Phone:406-782-0417
Mailing Address - Fax:406-782-6964
Practice Address - Street 1:111 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:BUTTE
Practice Address - State:MT
Practice Address - Zip Code:59701-9223
Practice Address - Country:US
Practice Address - Phone:406-782-6626
Practice Address - Fax:406-782-6676
Is Sole Proprietor?:No
Enumeration Date:2019-07-24
Last Update Date:2019-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1259101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)