Healthcare Provider Details

I. General information

NPI: 1821600560
Provider Name (Legal Business Name): KALLIE JADE SPOONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2020
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11071 W MAPLE RD
OMAHA NE
68164-2604
US

IV. Provider business mailing address

11071 W MAPLE RD
OMAHA NE
68164-2604
US

V. Phone/Fax

Practice location:
  • Phone: 402-932-8884
  • Fax: 402-932-8885
Mailing address:
  • Phone: 402-932-8884
  • Fax: 402-932-8885

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number15096
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: