Basic Information
| Provider Information | |||||||||
| NPI: | 1770922437 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ALEGENT CREIGHTON HEALTH | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CHI HEALTH PSYCHIATRIC ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12809 W DODGE ROAD | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681542155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023986255 | ||||||||
| FaxNumber: | 4028298513 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 MERCY DR | ||||||||
| Address2: | |||||||||
| City: | COUNCIL BLUFFS | ||||||||
| State: | IA | ||||||||
| PostalCode: | 515033128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7123282609 | ||||||||
| FaxNumber: | 7123289257 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2013 | ||||||||
| LastUpdateDate: | 10/30/2020 | ||||||||
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| AuthorizedOfficialLastName: | JANKUSKI | ||||||||
| AuthorizedOfficialFirstName: | KEITH | ||||||||
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| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 4023434409 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CHI NEBRASKA | ||||||||
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| NPICertificationDate: | 10/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Clinical Neuropsychologist | 103T00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 1041C0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 163W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | 101Y00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | 101YM0800X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 364S00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | 2084P0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.