Provider Demographics
NPI:1558789768
Name:NIX, JENNIFER LYN (MA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYN
Last Name:NIX
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 7TH ST E
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55106-4039
Mailing Address - Country:US
Mailing Address - Phone:651-332-5502
Mailing Address - Fax:651-332-5738
Practice Address - Street 1:1301 7TH ST E
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55106-4039
Practice Address - Country:US
Practice Address - Phone:651-332-5502
Practice Address - Fax:651-332-5738
Is Sole Proprietor?:No
Enumeration Date:2014-04-03
Last Update Date:2014-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN101Y00000X101Y00000X
MN101YM0800X101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor