Healthcare Provider Details

I. General information

NPI: 1669612503
Provider Name (Legal Business Name): JERRY VAN WINKLE, PSYD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2009
Last Update Date: 04/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2315 W 39TH ST
KEARNEY NE
68845-8327
US

IV. Provider business mailing address

2315 W 39TH ST
KEARNEY NE
68845-8327
US

V. Phone/Fax

Practice location:
  • Phone: 308-224-4664
  • Fax: 308-237-5581
Mailing address:
  • Phone: 308-224-4664
  • Fax: 308-237-5581

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number577
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number577
License Number StateNE

VIII. Authorized Official

Name: DR. JERRY ALAN VAN WINKLE
Title or Position: PSYCHOLOGIST
Credential: PSYD
Phone: 308-224-4664