Healthcare Provider Details

I. General information

NPI: 1376803213
Provider Name (Legal Business Name): JESSICA MACK DEMARCO PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA L. MACK PSYD

II. Dates (important events)

Enumeration Date: 05/25/2012
Last Update Date: 11/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6829 N 72ND ST SUITE 4700
OMAHA NE
68122-1723
US

IV. Provider business mailing address

7261 MERCY RD
OMAHA NE
68124-2311
US

V. Phone/Fax

Practice location:
  • Phone: 402-572-2169
  • Fax: 402-572-3479
Mailing address:
  • Phone: 402-398-6255
  • Fax: 402-829-8513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number849
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number849
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: