MEDICARE: NICOLE JACQUES LSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	115845	IL
2	2084N0400X	Neurology Physician	115845	IL

General Provider Information

NPI Number	:	1013870609
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE JACQUES LSW

Provider Business Mailing Address
First Line	:	2002 16TH AVE
Second Line	:
City	:	KENOSHA
State	:	WI
Zip	:	53140-4711
Country	:	US
Telephone Number	:	262-496-5863
Fax Number	:

Provider Business Practice Location Address
First Line	:	1860 W WINCHESTER RD STE 106
Second Line	:
City	:	LIBERTYVILLE
State	:	IL
Zip	:	60048-5312
Country	:	US
Telephone Number	:	262-496-5863
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/09/2025
Last Update Date	:	12/09/2025

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Directions to “ NICOLE JACQUES LSW” Practice Location

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