Basic Information
| Provider Information | |||||||||
| NPI: | 1437453677 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JESSEN | ||||||||
| FirstName: | BLAKE | ||||||||
| MiddleName: | T. | ||||||||
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| Credential: | MPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3755 | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681030755 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023542100 | ||||||||
| FaxNumber: | 4023542155 | ||||||||
| Practice Location | |||||||||
| Address1: | 16120 W DODGE RD | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681182049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023540410 | ||||||||
| FaxNumber: | 4002354041 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2011 | ||||||||
| LastUpdateDate: | 12/22/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 1661 | NE | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 10025941700 | 05 | NE | MEDICAID | 10025895900 | 05 | NE | MEDICAID | 10025896100 | 05 | NE | MEDICAID | 10026252200 | 05 | NE | MEDICAID | 1437453677 | 05 | IA | MEDICAID | 10025896000 | 05 | NE | MEDICAID | 10026056700 | 05 | NE | MEDICAID |