Basic Information
| Provider Information | |||||||||
| NPI: | 1639430416 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LACY | ||||||||
| FirstName: | JORDAN | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8005 FARNAM DR | ||||||||
| Address2: | STE 305 | ||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681143426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023989243 | ||||||||
| FaxNumber: | 4023989253 | ||||||||
| Practice Location | |||||||||
| Address1: | 982035 NEBRASKA MEDICAL CTR | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681982035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4025599605 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2012 | ||||||||
| LastUpdateDate: | 08/16/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | 6729 | NE | Y | Allopathic & Osteopathic Physicians | Neurological Surgery |
No ID Information.