Healthcare Provider Details

I. General information

NPI: 1083863930
Provider Name (Legal Business Name): JAY B NICKEL LPC-S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2008
Last Update Date: 10/11/2022
Certification Date: 10/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

282 OLD KYLE RD
WIMBERLEY TX
78676-9701
US

IV. Provider business mailing address

8956 RESEARCH BLVD BLDG 2
AUSTIN TX
78758-5902
US

V. Phone/Fax

Practice location:
  • Phone: 512-663-5941
  • Fax: 575-448-7404
Mailing address:
  • Phone: 512-451-7337
  • Fax: 512-451-8729

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number61764
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: