Provider Demographics
NPI:1093475477
Name:NICCOLAI, JACQUELINE PATRICIA (LPC-IT)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:PATRICIA
Last Name:NICCOLAI
Suffix:
Gender:F
Credentials:LPC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7919 48TH AVE
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-2023
Mailing Address - Country:US
Mailing Address - Phone:602-565-6662
Mailing Address - Fax:
Practice Address - Street 1:6121 GREENBAY RD
Practice Address - Street 2:SUITE 200
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142
Practice Address - Country:US
Practice Address - Phone:262-694-3718
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-27
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor