Provider Demographics
NPI:1194319418
Name:JACKSON, NATHAN EDWARD
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:EDWARD
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:507 GASLIGHT LN APT 3
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:NE
Mailing Address - Zip Code:68005-2663
Mailing Address - Country:US
Mailing Address - Phone:402-889-7284
Mailing Address - Fax:
Practice Address - Street 1:4101 WOOLWORTH AVE
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68105-1850
Practice Address - Country:US
Practice Address - Phone:800-451-5796
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-26
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE7574104100000X
NE12473101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health