Provider Demographics
NPI:1417380957
Name:NICK, JESSICA LYNN (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:LYNN
Last Name:NICK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71 ENT RD
Mailing Address - Street 2:
Mailing Address - City:HANSCOM AFB
Mailing Address - State:MA
Mailing Address - Zip Code:01731-2605
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:71 ENT RD
Practice Address - Street 2:
Practice Address - City:HANSCOM AFB
Practice Address - State:MA
Practice Address - Zip Code:01731-2605
Practice Address - Country:US
Practice Address - Phone:781-325-1605
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-20
Last Update Date:2013-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA218829104100000X
OH1100634104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker