MEDICARE: JESSICA HEREK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	2255A2300X	Athletic Trainer

General Provider Information

NPI Number	:	1255732889
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA HEREK

Provider Business Mailing Address
First Line	:	3015 S 134TH AVE
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68144-3516
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3015 S 134TH AVE
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68144-3516
Country	:	US
Telephone Number	:	402-312-5969
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/15/2014
Last Update Date	:	09/15/2014

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Directions to “ JESSICA HEREK ” Practice Location

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