Healthcare Provider Details

I. General information

NPI: 1629997374
Provider Name (Legal Business Name): RENEE JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2026
Last Update Date: 07/14/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2930 N 108TH ST
OMAHA NE
68164-3710
US

IV. Provider business mailing address

2027 N 83RD ST
OMAHA NE
68134-6301
US

V. Phone/Fax

Practice location:
  • Phone: 402-709-1964
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: