Healthcare Provider Details

I. General information

NPI: 1316865744
Provider Name (Legal Business Name): MR. ANDRE LEE JACKSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2026
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2115 N 27TH ST
OMAHA NE
68111-4337
US

IV. Provider business mailing address

2115 N 27TH ST
OMAHA NE
68111-4337
US

V. Phone/Fax

Practice location:
  • Phone: 402-949-8534
  • Fax:
Mailing address:
  • Phone: 402-949-8534
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code342000000X
TaxonomyTransportation Network Company
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: