Provider Demographics
NPI:1992516397
Name:NICKERSON, AMANDA JANE
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:JANE
Last Name:NICKERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2795 PINERIDGE CT NW APT C
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49534-7511
Mailing Address - Country:US
Mailing Address - Phone:231-313-1882
Mailing Address - Fax:
Practice Address - Street 1:103 W 3RD ST # E
Practice Address - Street 2:
Practice Address - City:KALKASKA
Practice Address - State:MI
Practice Address - Zip Code:49646-5107
Practice Address - Country:US
Practice Address - Phone:231-313-1882
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-15
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker