Provider Demographics
NPI:1942964838
Name:NICKELSEN, JOSHUA PHILLIP
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:PHILLIP
Last Name:NICKELSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3630 SE CESAR E CHAVEZ BLVD APT 11
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-1700
Mailing Address - Country:US
Mailing Address - Phone:917-617-4741
Mailing Address - Fax:
Practice Address - Street 1:3630 SE CESAR E CHAVEZ BLVD APT 11
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-1700
Practice Address - Country:US
Practice Address - Phone:917-617-4741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-26
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR26433225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist