Provider Demographics
NPI:1184402463
Name:NICKELSEN, JAMES (LMFT)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:NICKELSEN
Suffix:
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 1:420 S ESPLANADE ST APT F404
Mailing Address - Street 2:
Mailing Address - City:LEAVENWORTH
Mailing Address - State:KS
Mailing Address - Zip Code:66048-1522
Mailing Address - Country:US
Mailing Address - Phone:913-915-1183
Mailing Address - Fax:
Practice Address - Street 1:205 S 5TH ST UNIT 13
Practice Address - Street 2:
Practice Address - City:LEAVENWORTH
Practice Address - State:KS
Practice Address - Zip Code:66048-2602
Practice Address - Country:US
Practice Address - Phone:913-271-7099
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-19
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS03434-T106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist