Healthcare Provider Details

I. General information

NPI: 1497603898
Provider Name (Legal Business Name): JAY HOWARD GUSTAFSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2026
Last Update Date: 03/20/2026
Certification Date: 03/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

87765 WILLOW RIDGE LN
LONG PINE NE
69217-5287
US

IV. Provider business mailing address

PO BOX 351
AINSWORTH NE
69210-0351
US

V. Phone/Fax

Practice location:
  • Phone: 402-760-1078
  • Fax:
Mailing address:
  • Phone: 402-760-1078
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: