Individual
JACK LEE NICHOLSON I
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
460 AZTEC LN, LATHROP, CA 95330-9142
(209) 451-8732
Mailing address
460 AZTEC LN, LATHROP, CA 95330-9142
Taxonomy
Speciality
Code
Description
License number
State
3747A0650X
Attendant Care Provider
Primary
—
CA
3747A0650X
Attendant Care Provider
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
193200000X
—
CA
05
—
1933200000X
—
CA
05
—
3747A0650X
—
CA
Enumeration date
09/08/2019
Last updated
09/08/2019
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