Provider Demographics
NPI:1467792036
Name:NICKERSON, JESSICA (LCSW)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:NICKERSON
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 1:1329 AMMON PARK DR
Mailing Address - Street 2:
Mailing Address - City:AMMON
Mailing Address - State:ID
Mailing Address - Zip Code:83406-4591
Mailing Address - Country:US
Mailing Address - Phone:208-534-5554
Mailing Address - Fax:208-534-5580
Practice Address - Street 1:1329 AMMON PARK DR
Practice Address - Street 2:
Practice Address - City:AMMON
Practice Address - State:ID
Practice Address - Zip Code:83406-4591
Practice Address - Country:US
Practice Address - Phone:208-534-5554
Practice Address - Fax:208-534-5580
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-19
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-341841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical