MEDICARE: MS. STACY JEAN NIELSEN LCSW

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	104100000X	Social Worker
2	1041C0700X	Clinical Social Worker	L6376	OR

General Provider Information

NPI Number	:	1659608115
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. STACY JEAN NIELSEN LCSW

Provider Business Mailing Address
First Line	:	1400 EXECUTIVE PKWY STE 260
Second Line	:
City	:	EUGENE
State	:	OR
Zip	:	97401-7121
Country	:	US
Telephone Number	:	541-802-6597
Fax Number	:

Provider Business Practice Location Address
First Line	:	29398 RECOVERY WAY
Second Line	:
City	:	JUNCTION CITY
State	:	OR
Zip	:	97448-8447
Country	:	US
Telephone Number	:	541-465-2505
Fax Number	:

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

Provider Enumeration Date	:	11/04/2009
Last Update Date	:	11/27/2023

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