Provider Demographics
NPI:1871131482
Name:NICHOLS, JENNIFER A (LPC-IT, SAC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:LPC-IT, SAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 MASON STREET, SUITE 11
Mailing Address - Street 2:
Mailing Address - City:ONALASKA
Mailing Address - State:WI
Mailing Address - Zip Code:54650
Mailing Address - Country:US
Mailing Address - Phone:608-769-6784
Mailing Address - Fax:
Practice Address - Street 1:200 MASON ST STE 11
Practice Address - Street 2:
Practice Address - City:ONALASKA
Practice Address - State:WI
Practice Address - Zip Code:54650-7061
Practice Address - Country:US
Practice Address - Phone:608-769-6784
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-13
Last Update Date:2020-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16360-131101YA0400X
WI4346-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI4346-226OtherSTATE OF WISCONSIN