Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 1041C0700X | Clinical Social Worker | 8977595-3501 | UT |
Y | 1041C0700X | Clinical Social Worker | LW61179889 | WA |
NPI | 1003266206 |
---|---|
Provider Name | Ms. Nichole L Jardine |
First Address | Providence, UT 84332-0583 |
Second Address | Spokane, WA 99201-0580 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/06/2016 |
Last Update Date | 03/09/2021 |