Basic Information
| Provider Information | |||||||||
| NPI: | 1659336675 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VIDRA | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LMHP, CPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 333 W NORFOLK AVE | ||||||||
| Address2: | STE 201 | ||||||||
| City: | NORFOLK | ||||||||
| State: | NE | ||||||||
| PostalCode: | 687015401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023792030 | ||||||||
| FaxNumber: | 4023793933 | ||||||||
| Practice Location | |||||||||
| Address1: | 333 W NORFOLK AVE | ||||||||
| Address2: | STE 201 | ||||||||
| City: | NORFOLK | ||||||||
| State: | NE | ||||||||
| PostalCode: | 687015401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023792030 | ||||||||
| FaxNumber: | 4023793933 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 101YP2500X | 1170 | NE | X | Behavioral Health & Social Service Providers | Counselor | Professional | 101YM0800X | 2041 | NE | X | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 113522 | 01 | NE | OPTUM LIFE ERA | OTHER | 39189435426 | 05 | NE | MEDICAID | 24147 | 01 | NE | MIDLANDS CHOICE | OTHER | 84322 | 01 | NE | BC/BS | OTHER |