Healthcare Provider Details

I. General information

NPI: 1104732817
Provider Name (Legal Business Name): JARED OLIVARES GONZALEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2026
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 W ROSE ST
LINCOLN NE
68522-4470
US

IV. Provider business mailing address

224 FURNAS AVE
LINCOLN NE
68521-2932
US

V. Phone/Fax

Practice location:
  • Phone: 402-508-2540
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: