1922399187 NPI number — JENNIFER M BRUURSEMA DPT

Table of content: JENNIFER M BRUURSEMA DPT (NPI 1922399187)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922399187 NPI number — JENNIFER M BRUURSEMA DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRUURSEMA
Provider First Name:
JENNIFER
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BOGNICH
Provider Other First Name:
JENNIFER
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DPT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1922399187
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/23/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18101 R PLAZA
Provider Second Line Business Mailing Address:
SUITE 106
Provider Business Mailing Address City Name:
OMAHA
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68135-1929
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-933-8333
Provider Business Mailing Address Fax Number:
402-933-4755

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18101 R PLAZA
Provider Second Line Business Practice Location Address:
SUITE 106
Provider Business Practice Location Address City Name:
OMAHA
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68135-1929
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-933-8333
Provider Business Practice Location Address Fax Number:
402-933-4755
Provider Enumeration Date:
04/22/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  2964 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 10025395000 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".




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