Healthcare Provider Details

I. General information

NPI: 1811656093
Provider Name (Legal Business Name): JACKSON HOFMEISTER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2021
Last Update Date: 12/15/2021
Certification Date: 12/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4614 S 132ND ST
OMAHA NE
68137-1764
US

IV. Provider business mailing address

4614 S 132ND ST
OMAHA NE
68137-1764
US

V. Phone/Fax

Practice location:
  • Phone: 402-330-3211
  • Fax: 402-330-5970
Mailing address:
  • Phone: 402-330-3211
  • Fax: 402-330-5970

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number4311
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: