Healthcare Provider Details

I. General information

NPI: 1164860268
Provider Name (Legal Business Name): JENNIFER R MICHAELIS PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2013
Last Update Date: 02/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16120 W DODGE RD
OMAHA NE
68118-2049
US

IV. Provider business mailing address

PO BOX 3755
OMAHA NE
68103-0755
US

V. Phone/Fax

Practice location:
  • Phone: 402-354-0707
  • Fax: 402-354-0711
Mailing address:
  • Phone: 402-354-2100
  • Fax: 402-354-2155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1825
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number074838
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: