Provider Demographics
NPI:1497909733
Name:YACKOVICH, NICK S JR (PHD)
Entity Type:Individual
Prefix:DR
First Name:NICK
Middle Name:S
Last Name:YACKOVICH
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:4222 MILWAUKEE ST.
Mailing Address - Street 2:SUITE 2
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53714
Mailing Address - Country:US
Mailing Address - Phone:608-215-0600
Mailing Address - Fax:608-246-8199
Practice Address - Street 1:4222 MILWAUKEE ST
Practice Address - Street 2:SUITE 2
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53714-3508
Practice Address - Country:US
Practice Address - Phone:608-215-0600
Practice Address - Fax:608-246-8199
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-13
Last Update Date:2013-05-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI2755-057103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40952500Medicaid