Provider Demographics
NPI:1124115043
Name:VAN WINKLE, JERRY ALAN (PSYD)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:ALAN
Last Name:VAN WINKLE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2315 W 39TH ST
Mailing Address - Street 2:
Mailing Address - City:KEARNEY
Mailing Address - State:NE
Mailing Address - Zip Code:68845-8327
Mailing Address - Country:US
Mailing Address - Phone:308-224-4664
Mailing Address - Fax:308-237-5581
Practice Address - Street 1:2315 W 39TH ST
Practice Address - Street 2:
Practice Address - City:KEARNEY
Practice Address - State:NE
Practice Address - Zip Code:68845-8327
Practice Address - Country:US
Practice Address - Phone:308-224-4664
Practice Address - Fax:308-237-5581
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE577103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025728500Medicaid
NE10025728500Medicaid