MEDICARE: JACQUELINE PATRICIA NICCOLAI LPC

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	101YM0800X	Mental Health Counselor	TPMC6693	FL
2	101YM0800X	Mental Health Counselor	068.0136820TELE	VT
3	101YP2500X	Professional Counselor	10474-125	WI

General Provider Information

NPI Number	:	1093475477
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELINE PATRICIA NICCOLAI LPC

Provider Business Mailing Address
First Line	:	7919 48TH AVE
Second Line	:
City	:	KENOSHA
State	:	WI
Zip	:	53142-2023
Country	:	US
Telephone Number	:	602-565-6662
Fax Number	:

Provider Business Practice Location Address
First Line	:	7919 48TH AVE STE 200
Second Line	:
City	:	KENOSHA
State	:	WI
Zip	:	53142-2023
Country	:	US
Telephone Number	:	414-622-0157
Fax Number	:

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

Provider Enumeration Date	:	12/27/2021
Last Update Date	:	04/17/2026

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