Provider Demographics
NPI:1700534799
Name:JESSICA GROSSNICKLAUS, PSYD, LLC
Entity Type:Organization
Organization Name:JESSICA GROSSNICKLAUS, PSYD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:GROSSNICKLAUS
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:308-289-1026
Mailing Address - Street 1:2001 PINE LAKE RD STE 200
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68512-3604
Mailing Address - Country:US
Mailing Address - Phone:308-289-1026
Mailing Address - Fax:
Practice Address - Street 1:2001 PINE LAKE RD STE 200
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68512-3604
Practice Address - Country:US
Practice Address - Phone:402-261-8313
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-17
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)