MEDICARE: BRANDON JAMAR PETTIS

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	374U00000X	Home Health Aide		NE

General Provider Information

NPI Number	:	1922963560
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRANDON JAMAR PETTIS

Provider Business Mailing Address
First Line	:	4324 OHIO ST
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68111-3444
Country	:	US
Telephone Number	:	531-232-3299
Fax Number	:

Provider Business Practice Location Address
First Line	:	4324 OHIO ST
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68111-3444
Country	:	US
Telephone Number	:	531-323-3299
Fax Number	:

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

Provider Enumeration Date	:	12/17/2025
Last Update Date	:	12/17/2025

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Directions to “ BRANDON JAMAR PETTIS ” Practice Location

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