Healthcare Provider Details

I. General information

NPI: 1720998255
Provider Name (Legal Business Name): JACK ROBERT COSGROVE OTD, OTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2026
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17500 BURKE ST
OMAHA NE
68118-2244
US

IV. Provider business mailing address

5401 SOUTH ST
LINCOLN NE
68506-2150
US

V. Phone/Fax

Practice location:
  • Phone: 402-401-3900
  • Fax:
Mailing address:
  • Phone: 402-413-3900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number3160
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: