Provider Demographics
NPI:1336554633
Name:NICOTRA, JENNIFER (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:NICOTRA
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 1ST ST S
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33880-3904
Mailing Address - Country:US
Mailing Address - Phone:863-293-1121
Mailing Address - Fax:
Practice Address - Street 1:1201 1ST ST S
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33880-3904
Practice Address - Country:US
Practice Address - Phone:863-293-1121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-25
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW12009171M00000X
FL1200091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator