Basic Information
| Provider Information | |||||||||
| NPI: | 1184078974 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REZAC | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | |||||||||
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| OtherLastName: | REZAC | ||||||||
| OtherFirstName: | JACKIE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 424 W 23RD ST STE E | ||||||||
| Address2: | |||||||||
| City: | FREMONT | ||||||||
| State: | NE | ||||||||
| PostalCode: | 680251211 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 424 W 23RD ST STE E | ||||||||
| Address2: | |||||||||
| City: | FREMONT | ||||||||
| State: | NE | ||||||||
| PostalCode: | 680251211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4026148444 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2016 | ||||||||
| LastUpdateDate: | 04/18/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 10836 | NE | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.