Provider Demographics
NPI:1629477260
Name:NICKELSON-JACKSON, CALISA (LPCC)
Entity Type:Individual
Prefix:MRS
First Name:CALISA
Middle Name:
Last Name:NICKELSON-JACKSON
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1075 BEECHER XING N
Mailing Address - Street 2:SUITE C
Mailing Address - City:GAHANNA
Mailing Address - State:OH
Mailing Address - Zip Code:43230-4572
Mailing Address - Country:US
Mailing Address - Phone:614-787-8218
Mailing Address - Fax:
Practice Address - Street 1:1075 BEECHER CROSSING N.
Practice Address - Street 2:SUITE C
Practice Address - City:GAHANNA
Practice Address - State:OH
Practice Address - Zip Code:43230-3069
Practice Address - Country:US
Practice Address - Phone:614-787-8218
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-20
Last Update Date:2017-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional