Healthcare Provider Details

I. General information

NPI: 1154813376
Provider Name (Legal Business Name): JESSICA J CLYDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA J KLUG

II. Dates (important events)

Enumeration Date: 06/04/2018
Last Update Date: 09/13/2024
Certification Date: 09/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 W NORFOLK AVE STE 201
NORFOLK NE
68701-5221
US

IV. Provider business mailing address

333 W NORFOLK AVE STE 201
NORFOLK NE
68701-5221
US

V. Phone/Fax

Practice location:
  • Phone: 402-379-2030
  • Fax: 402-379-3933
Mailing address:
  • Phone: 402-379-2030
  • Fax: 402-379-3933

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: