| Doctor Name: | JEANETTE IDA NICOLAS |
| NPI Number: | 1043539612 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | |
| License Number: | |
| Business Practice Address: | 13741 Foothill Blvd Ste 270 Sylmar, CA - 913423150 |
| Business Phone Number: | 8188339789 |
| Business Fax Number: | 8188339790 |
| Mailing Address: | 13741 Foothill Blvd Ste 270, SYLMAR |
| State: | CA |
| Postal Code: | 913423150 |
| Phone Number: | 8188339789 |
| Fax Number: | 8188339790 |
| NPI Enumeration Date: | 05/21/2010 |
| NPI Last Update Date: | 05/21/2010 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YA0400X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Addiction (Substance Use Disorder) |
| Taxonomy Definition: | |