Provider Demographics
NPI:1881242691
Name:GROSSNICKLAUS, JESSICA MARIE (PSYD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:GROSSNICKLAUS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:MARIE
Other - Last Name:PALOUCEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
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:402-261-8313
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:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-27
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KST-LMLP2938103T00000X
NE1082103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist