Provider Demographics
NPI:1669985198
Name:NICHOLS, JACKI (SA-C)
Entity type:Individual
Prefix:MRS
First Name:JACKI
Middle Name:
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5055 N ROCK CANYON RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85750-6003
Mailing Address - Country:US
Mailing Address - Phone:520-577-0293
Mailing Address - Fax:
Practice Address - Street 1:5055 N ROCK CANYON RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85750-6003
Practice Address - Country:US
Practice Address - Phone:520-577-0293
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-06
Last Update Date:2019-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant