Provider Demographics
NPI:1538686803
Name:NICKELS, JENNIFER A (MA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:NICKELS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:LAFOREST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7108 S KANNER HWY
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34997
Mailing Address - Country:US
Mailing Address - Phone:855-832-6727
Mailing Address - Fax:
Practice Address - Street 1:400 RENAISSANCE CTR.
Practice Address - Street 2:SUITE 2600
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48243-1502
Practice Address - Country:US
Practice Address - Phone:855-832-6727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-27
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician