Basic Information
| Provider Information | |||||||||
| NPI: | 1356699441 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FREEBURG | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CSW | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4110 AVENUE D | ||||||||
| Address2: | |||||||||
| City: | SCOTTSBLUFF | ||||||||
| State: | NE | ||||||||
| PostalCode: | 693614650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3086353171 | ||||||||
| FaxNumber: | 3086359672 | ||||||||
| Practice Location | |||||||||
| Address1: | 4110 AVENUE D | ||||||||
| Address2: | |||||||||
| City: | SCOTTSBLUFF | ||||||||
| State: | NE | ||||||||
| PostalCode: | 693614650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3086353171 | ||||||||
| FaxNumber: | 3086359672 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2012 | ||||||||
| LastUpdateDate: | 08/21/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 47051963380 | 05 | NE | MEDICAID |