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General NPI Number Information
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NPI Number | 1205763893
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Entity Type | Individual
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Provider Name | VIRGIL JACKSON
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Gender | Male
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Dates
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Enumeration Date | 05/06/2026
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Last Update Date | 05/06/2026
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Provider Practice Location Address
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Address Line | 2507 N 187TH AVE
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City | ELKHORN
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State | NE
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Zip | 68022-4539
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Country | US
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Telephone | 918-304-9225
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Fax |
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Provider Business Mailing Address
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Address Line | 4805 N 72ND ST
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City | OMAHA
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State | NE
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Zip | 68134-2304
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 253J00000X
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Taxonomy Name | Foster Care Agency
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License Number |
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License Number State | NE
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