Provider Demographics
NPI:1891475794
Name:NICKELS, JAZMINE
Entity Type:Individual
Prefix:
First Name:JAZMINE
Middle Name:
Last Name:NICKELS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3370 SAINT ROSE PKWY APT 616
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052-4243
Mailing Address - Country:US
Mailing Address - Phone:702-419-0023
Mailing Address - Fax:
Practice Address - Street 1:3140 S RAINBOW BLVD STE 400
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-6234
Practice Address - Country:US
Practice Address - Phone:702-706-7635
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-24
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV22-243949106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician