Provider Demographics
NPI:1043371958
Name:NICHOLS, JON ROSS (DC)
Entity type:Individual
Prefix:DR
First Name:JON
Middle Name:ROSS
Last Name:NICHOLS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 SW 2ND AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:CANBY
Mailing Address - State:OR
Mailing Address - Zip Code:97013-4157
Mailing Address - Country:US
Mailing Address - Phone:503-829-6176
Mailing Address - Fax:503-829-6178
Practice Address - Street 1:317 N MOLALLA AVE
Practice Address - Street 2:
Practice Address - City:MOLALLA
Practice Address - State:OR
Practice Address - Zip Code:97038-8840
Practice Address - Country:US
Practice Address - Phone:503-829-6176
Practice Address - Fax:503-829-6178
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR6222111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC25361Medicare ID - Type Unspecified