Provider Demographics
NPI:1598280661
Name:NICKUM, JOSEPHINE ANNA (MED, LMHC)
Entity type:Individual
Prefix:
First Name:JOSEPHINE
Middle Name:ANNA
Last Name:NICKUM
Suffix:
Gender:F
Credentials:MED, LMHC
Other - Prefix:
Other - First Name:JOSIE
Other - Middle Name:ANNA
Other - Last Name:NICKUM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3888 NW RANDALL WAY STE 201
Mailing Address - Street 2:
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-7847
Mailing Address - Country:US
Mailing Address - Phone:360-698-5883
Mailing Address - Fax:360-809-6002
Practice Address - Street 1:3888 NW RANDALL WAY STE 201
Practice Address - Street 2:
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-7847
Practice Address - Country:US
Practice Address - Phone:360-698-5883
Practice Address - Fax:360-698-5883
Is Sole Proprietor?:No
Enumeration Date:2017-08-09
Last Update Date:2024-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH60947420101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2116270Medicaid