Provider Demographics
NPI:1649059312
Name:NICKERSON, VIRGINIA JENELLE (SLP-A)
Entity type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:JENELLE
Last Name:NICKERSON
Suffix:
Gender:F
Credentials:SLP-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3117 PARTIPILO ST
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72653-5855
Mailing Address - Country:US
Mailing Address - Phone:501-206-4555
Mailing Address - Fax:
Practice Address - Street 1:2465 RODEO DR
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653-4501
Practice Address - Country:US
Practice Address - Phone:501-206-4555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-22
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2023722355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant