Provider Demographics
NPI:1629563002
Name:NICHOLS, JEANA
Entity type:Individual
Prefix:
First Name:JEANA
Middle Name:
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JEANA
Other - Middle Name:
Other - Last Name:BAKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:203 N WASHINGTON ST STE 300
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99201-0254
Mailing Address - Country:US
Mailing Address - Phone:509-444-8888
Mailing Address - Fax:509-444-7806
Practice Address - Street 1:501 N RIVERPOINT BLVD STE 245
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99202-1649
Practice Address - Country:US
Practice Address - Phone:509-232-8138
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-27
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174H00000X
WADH60675114124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
No174H00000XOther Service ProvidersHealth Educator