Basic Information
| Provider Information | |||||||||
| NPI: | 1386907806 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CANTRELL | ||||||||
| FirstName: | JODI | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 988102 NEBRASKA MEDICAL CTR | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681988102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4025596195 | ||||||||
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| Practice Location | |||||||||
| Address1: | EMILE 42ND ST | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681980001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4025594015 | ||||||||
| FaxNumber: | 4025598715 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2012 | ||||||||
| LastUpdateDate: | 05/13/2016 | ||||||||
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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 | 207R00000X | 6772 | NE | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | 6772 | NE | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 6772 | 01 | NE | TEMPORARY EDUCATION PERMIT | OTHER |