Provider Demographics
NPI:1194228023
Name:NICODEMUS, JENEANE C (LMFT)
Entity Type:Individual
Prefix:
First Name:JENEANE
Middle Name:C
Last Name:NICODEMUS
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:424 BAKER AVE UNIT 4687
Mailing Address - Street 2:
Mailing Address - City:WHITEFISH
Mailing Address - State:MT
Mailing Address - Zip Code:59937-7114
Mailing Address - Country:US
Mailing Address - Phone:805-635-7108
Mailing Address - Fax:
Practice Address - Street 1:518 TAMARACK CREEK RD
Practice Address - Street 2:
Practice Address - City:WHITEFISH
Practice Address - State:MT
Practice Address - Zip Code:59937
Practice Address - Country:US
Practice Address - Phone:805-635-7108
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-16
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA128506101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor