Healthcare Provider Details

I. General information

NPI: 1336322866
Provider Name (Legal Business Name): JOLENE MARIE LIES PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS JOLENE MARIE LUKASIEWICZ

II. Dates (important events)

Enumeration Date: 12/06/2007
Last Update Date: 06/09/2025
Certification Date: 06/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5005 S 153RD ST STE 100
OMAHA NE
68137-5070
US

IV. Provider business mailing address

7261 MERCY RD
OMAHA NE
68124-2311
US

V. Phone/Fax

Practice location:
  • Phone: 402-717-1255
  • Fax: 402-818-1924
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number111296
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number672
License Number StateNE
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number672
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: