=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821896093
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JERRY BARTHOLOMEW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/04/2025
-----------------------------------------------------
Last Update Date | 03/04/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 545 MADA STREET
-----------------------------------------------------
City | HALLAM
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68368
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-263-2614
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 220 OAKCREEK DR # NE68528
-----------------------------------------------------
City | LINCOLN
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68528-1587
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-817-4959
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 373H00000X
-----------------------------------------------------
Taxonomy Name | Day Training/Habilitation Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------