Healthcare Provider Details

I. General information

NPI: 1093368805
Provider Name (Legal Business Name): SKYLAR JORDAN NICHOLS LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2019
Last Update Date: 05/25/2026
Certification Date: 05/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1129 MACKLIND AVE
SAINT LOUIS MO
63110-1440
US

IV. Provider business mailing address

6202 ARTHUR AVE
SAINT LOUIS MO
63139-2017
US

V. Phone/Fax

Practice location:
  • Phone: 314-534-0200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC200002677
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.024865
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLICSW125947
License Number StateMA
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2022004433
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: