Provider Demographics
NPI:1508910662
Name:ICKES, JANE LEE (MSW)
Entity Type:Individual
Prefix:MRS
First Name:JANE
Middle Name:LEE
Last Name:ICKES
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:MS
Other - First Name:JANE
Other - Middle Name:YOUNG-SUN
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:5251-37 JOHN TYLER HWY
Mailing Address - Street 2:PLT'S ABA WELLNESS CLINIC
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23185
Mailing Address - Country:US
Mailing Address - Phone:757-846-6959
Mailing Address - Fax:
Practice Address - Street 1:5251-37 JOHN TYLER HWY
Practice Address - Street 2:PLT'S ABA WELLNESS CLINIC
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23185
Practice Address - Country:US
Practice Address - Phone:757-846-6959
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0056521041C0700X
VA09040076771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical