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General NPI Number Information
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NPI Number | 1669612503
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Entity Type | Organization
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Legal Business Name | JERRY VAN WINKLE, PSYD, LLC
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Dates
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Enumeration Date | 03/05/2009
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Last Update Date | 04/24/2014
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Provider Practice Location Address
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Address Line | 2315 W 39TH ST
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City | KEARNEY
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State | NE
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Zip | 68845-8327
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Country | US
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Telephone | 308-224-4664
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Fax | 308-237-5581
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Provider Business Mailing Address
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Address Line | 2315 W 39TH ST
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City | KEARNEY
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State | NE
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Zip | 68845-8327
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Country | US
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Telephone | 308-224-4664
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Fax | 308-237-5581
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Authorized Official
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Title or Position | PSYCHOLOGIST
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Name | DR. JERRY ALAN VAN WINKLE
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Credential | PSYD
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Telephone | 308-224-4664
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 577
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License Number State | NE
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Taxonomy #2
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 577
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License Number State | NE
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