Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 101YP1600X | Pastoral Counselor | ||
Y | 101YP2500X | Professional Counselor | 61764 | TX |
NPI | 1083863930 |
---|---|
Provider Name | Jay Nickel |
First Address | Wimberley, TX 78676-7714 |
Second Address | Wimberley, TX 78676-9701 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 16/09/2008 |
Last Update Date | 24/05/2016 |