Healthcare Provider Details

I. General information

NPI: 1982184362
Provider Name (Legal Business Name): JORDAN T ETHERINGTON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2018
Last Update Date: 04/13/2026
Certification Date: 04/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6902 PINE ST
OMAHA NE
68106-2855
US

IV. Provider business mailing address

985450 NEBRASKA MEDICAL CTR
OMAHA NE
68198-5450
US

V. Phone/Fax

Practice location:
  • Phone: 402-559-6418
  • Fax: 402-559-5737
Mailing address:
  • Phone: 402-559-8943
  • Fax: 402-559-5753

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number14819
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: