Provider Demographics
NPI:1053656652
Name:NIDEY, JACOB (LSW)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:NIDEY
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 BAYOU ST
Mailing Address - Street 2:
Mailing Address - City:VINCENNES
Mailing Address - State:IN
Mailing Address - Zip Code:47591-1034
Mailing Address - Country:US
Mailing Address - Phone:812-886-6800
Mailing Address - Fax:812-886-6809
Practice Address - Street 1:515 BAYOU ST
Practice Address - Street 2:
Practice Address - City:VINCENNES
Practice Address - State:IN
Practice Address - Zip Code:47591-1034
Practice Address - Country:US
Practice Address - Phone:812-886-6800
Practice Address - Fax:812-886-6809
Is Sole Proprietor?:No
Enumeration Date:2012-12-07
Last Update Date:2012-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN33006476A104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker