Provider Demographics
NPI:1073078689
Name:NICKEL, JACQUELINE (MS CCC SLP)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:NICKEL
Suffix:
Gender:F
Credentials:MS CCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2567 KINGSFIELD ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29466-7251
Mailing Address - Country:US
Mailing Address - Phone:412-726-3926
Mailing Address - Fax:800-603-6046
Practice Address - Street 1:3100 TRADITION CIR
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29466-7200
Practice Address - Country:US
Practice Address - Phone:843-654-7945
Practice Address - Fax:317-884-3388
Is Sole Proprietor?:No
Enumeration Date:2019-02-07
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6765235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist