Provider Demographics
NPI:1780138040
Name:NICKLAS, INAJANE (IMF)
Entity type:Individual
Prefix:
First Name:INAJANE
Middle Name:
Last Name:NICKLAS
Suffix:
Gender:F
Credentials:IMF
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 NOCUMI ST
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93001-4461
Mailing Address - Country:US
Mailing Address - Phone:805-404-0740
Mailing Address - Fax:
Practice Address - Street 1:3662 SHELDON DR
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-3138
Practice Address - Country:US
Practice Address - Phone:805-404-0740
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-04
Last Update Date:2016-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA70721106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist