Healthcare Provider Details

I. General information

NPI: 1174519318
Provider Name (Legal Business Name): JAN B REYNOLDS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/23/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 CAPEHART RD EHRLING BERGQUIST HOSPITAL - FAMILY ADVOCACY CLINIC
OFFUTT A F B NE
68113-1043
US

IV. Provider business mailing address

10867 POLK ST
OMAHA NE
68137-4700
US

V. Phone/Fax

Practice location:
  • Phone: 402-294-7886
  • Fax: 402-232-7291
Mailing address:
  • Phone: 402-294-7886
  • Fax: 402-232-7291

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLMHP - 1145/CMSW-683
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: