Provider Demographics
NPI:1063629624
Name:JACKMAN, NICOLE L (LCSW-C)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:L
Last Name:JACKMAN
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:L
Other - Last Name:KYKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW-C
Mailing Address - Street 1:1644 SAINT PAUL ST
Mailing Address - Street 2:
Mailing Address - City:HAMPSTEAD
Mailing Address - State:MD
Mailing Address - Zip Code:21074-2117
Mailing Address - Country:US
Mailing Address - Phone:410-257-0430
Mailing Address - Fax:
Practice Address - Street 1:7 SCHOOL HOUSE AVE STE 101
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:MD
Practice Address - Zip Code:21157-4566
Practice Address - Country:US
Practice Address - Phone:410-876-1233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD127801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD615501400Medicaid