Provider Demographics
NPI:1356988794
Name:NICKERSON, JOHN
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:NICKERSON
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 1:2327 E 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99202-3902
Mailing Address - Country:US
Mailing Address - Phone:509-808-8482
Mailing Address - Fax:
Practice Address - Street 1:947 E 35TH AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99203-3163
Practice Address - Country:US
Practice Address - Phone:509-995-3388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-04
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician