Healthcare Provider Details

I. General information

NPI: 1033560669
Provider Name (Legal Business Name): JORDAN BART
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2016
Last Update Date: 06/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

575 S 70TH ST STE 200
LINCOLN NE
68510-2471
US

IV. Provider business mailing address

1801 S 42ND ST
LINCOLN NE
68506-1112
US

V. Phone/Fax

Practice location:
  • Phone: 402-488-3322
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number634
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: