Provider Demographics
NPI:1093022527
Name:NICKERSON, SHAWNENE JAYNE (LCSW)
Entity Type:Individual
Prefix:
First Name:SHAWNENE
Middle Name:JAYNE
Last Name:NICKERSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:SHAWNENE
Other - Middle Name:JAYNE
Other - Last Name:NICKERSON-KIESER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 8232
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68108-0232
Mailing Address - Country:US
Mailing Address - Phone:208-329-3646
Mailing Address - Fax:
Practice Address - Street 1:1313 FARNAM ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68102-1881
Practice Address - Country:US
Practice Address - Phone:208-329-3646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-03
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-24582104100000X, 1041S0200X
NELICSW 14331041C0700X
IDLCSW317841041C0700X
IDCERTIF 10089 REF 743101YA0400X
IDIDAHO1041S0200X
NELIMHP 9641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)