1790857811 NPI number — JACK EVERIE CARLSON LIMHP LPC

Table of content: JACK EVERIE CARLSON LIMHP LPC (NPI 1790857811)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790857811 NPI number — JACK EVERIE CARLSON LIMHP LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CARLSON
Provider First Name:
JACK
Provider Middle Name:
EVERIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LIMHP LPC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790857811
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/16/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1900 SO 50TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LINCOLN
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68506
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-643-2800
Provider Business Mailing Address Fax Number:
402-643-4048

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
459 S 6TH ST
Provider Second Line Business Practice Location Address:
BLUE VALLEY BEHAVIORAL HEALTH
Provider Business Practice Location Address City Name:
SEWARD
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68434-2405
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-643-3343
Provider Business Practice Location Address Fax Number:
402-643-4048
Provider Enumeration Date:
11/14/2006

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: 101YM0800X , with the licence number:  2275 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 101YM0800X , with the licence number: 563 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 10025208600 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 470528515-06 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 470528515-09 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10025207900 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 470528515-00 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 470528515-14 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 470528515-15 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 47052851505 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 237457 . This is a "MIDLANDS CHOICE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 470528515-13 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 470528515-01 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 470528515-02 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 470528515-03 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 470528515-05 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 470528515-08 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 470528515-17 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 470528515-82 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10025668200 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 470528515-04 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 470528515-07 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".




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