Provider Demographics
NPI:1801211073
Name:FOSSETT, NICKEY R JR (LMFT)
Entity Type:Individual
Prefix:
First Name:NICKEY
Middle Name:R
Last Name:FOSSETT
Suffix:JR
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2045 SE HAWTHORNE BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-3819
Mailing Address - Country:US
Mailing Address - Phone:541-636-6180
Mailing Address - Fax:
Practice Address - Street 1:1017 ARTHUR ST
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97402
Practice Address - Country:US
Practice Address - Phone:541-636-6180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-25
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT1020106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500679774Medicaid