Provider Demographics
NPI:1114566197
Name:NICKERSON, JULIE ANN
Entity Type:Individual
Prefix:MRS
First Name:JULIE
Middle Name:ANN
Last Name:NICKERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16629 WILD HORSE CREEK RD
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63005-1627
Mailing Address - Country:US
Mailing Address - Phone:314-640-9105
Mailing Address - Fax:
Practice Address - Street 1:16629 WILD HORSE CREEK RD
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63005-1627
Practice Address - Country:US
Practice Address - Phone:314-640-9105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-23
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst