Healthcare Provider Details

I. General information

NPI: 1649653551
Provider Name (Legal Business Name): CHARLES DREW HEALTH CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2015
Last Update Date: 03/30/2021
Certification Date: 03/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4320 FORT ST
OMAHA NE
68111-1849
US

IV. Provider business mailing address

PO BOX 30019
OMAHA NE
68103-1119
US

V. Phone/Fax

Practice location:
  • Phone: 402-451-3553
  • Fax: 402-453-1970
Mailing address:
  • Phone: 402-451-3553
  • Fax: 402-453-1970

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNE
# 3
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateNE
# 4
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number StateNE
# 5
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNE
# 6
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateNE
# 7
Primary TaxonomyN
Taxonomy Code363LC1500X
TaxonomyCommunity Health Nurse Practitioner
License Number
License Number StateNE
# 8
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateNE

VIII. Authorized Official

Name: MISS TARSHA DENISE JACKSON
Title or Position: CFO
Credential:
Phone: 402-457-1215