Healthcare Provider Details

I. General information

NPI: 1770210908
Provider Name (Legal Business Name): JENNIFER JILL NICOLINI LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2022
Last Update Date: 08/08/2022
Certification Date: 08/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4580 HIGHWAY 158
HARVIELL MO
63945-8144
US

IV. Provider business mailing address

4580 HIGHWAY 158
HARVIELL MO
63945-8144
US

V. Phone/Fax

Practice location:
  • Phone: 573-872-0206
  • Fax:
Mailing address:
  • Phone: 573-872-0206
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number2021011705
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: