Healthcare Provider Details

I. General information

NPI: 1992090294
Provider Name (Legal Business Name): JESICA G. VICKERS LPC, LIMHP, PLADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2011
Last Update Date: 07/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 E 31ST ST
KEARNEY NE
68847-3001
US

IV. Provider business mailing address

3 WILLOW LN
KEARNEY NE
68845-4880
US

V. Phone/Fax

Practice location:
  • Phone: 308-234-6029
  • Fax:
Mailing address:
  • Phone: 308-920-0984
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberP-1114
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number4255
License Number StateNE
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1261
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: