Healthcare Provider Details

I. General information

NPI: 1487517975
Provider Name (Legal Business Name): JACOB EUGENE LAVILLE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2025
Last Update Date: 12/03/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1313 S SADDLE CREEK RD
OMAHA NE
68106-2402
US

IV. Provider business mailing address

1313 S SADDLE CREEK RD
OMAHA NE
68106-2402
US

V. Phone/Fax

Practice location:
  • Phone: 402-933-0100
  • Fax:
Mailing address:
  • Phone: 402-933-0100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number4875
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: