Healthcare Provider Details

I. General information

NPI: 1467818666
Provider Name (Legal Business Name): CHARLES DREW HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2016
Last Update Date: 03/19/2021
Certification Date: 03/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 NORTH 17TH STREET
OMAHA NE
68102-4119
US

IV. Provider business mailing address

2915 GRANT STREET
OMAHA NE
68111-3863
US

V. Phone/Fax

Practice location:
  • Phone: 402-346-8401
  • Fax: 402-453-2061
Mailing address:
  • Phone: 402-451-3553
  • Fax: 402-457-1220

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNE
# 3
Primary TaxonomyN
Taxonomy Code363LC1500X
TaxonomyCommunity Health Nurse Practitioner
License Number
License Number StateNE

VIII. Authorized Official

Name: MS. TARSHA DENISE JACKSON
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 402-457-1215