Healthcare Provider Details

I. General information

NPI: 1952941148
Provider Name (Legal Business Name): JACOB JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2020
Last Update Date: 01/15/2020
Certification Date: 01/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

815 K STREET
LINCOLN NE
68508
US

IV. Provider business mailing address

815 K STREET
LINCOLN NE
68508
US

V. Phone/Fax

Practice location:
  • Phone: 402-474-0011
  • Fax:
Mailing address:
  • Phone: 402-474-0011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1744
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number12068
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: