Basic Information
| Provider Information | |||||||||
| NPI: | 1952656514 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JARRELL | ||||||||
| FirstName: | PEGGY | ||||||||
| MiddleName: | JONES | ||||||||
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| Credential: | LCSW, LMHP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2797 | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681032797 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023544230 | ||||||||
| FaxNumber: | 4023546171 | ||||||||
| Practice Location | |||||||||
| Address1: | 8303 DODGE ST | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681144108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023548350 | ||||||||
| FaxNumber: | 4023548355 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2012 | ||||||||
| LastUpdateDate: | 12/13/2013 | ||||||||
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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 | 101YP2500X | 1016 | NE | Y | Behavioral Health & Social Service Providers | Counselor | Professional | 104100000X | 2291 | NE | N | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 470376604-33 | 05 | NE | MEDICAID | 1952656514 | 05 | IA | MEDICAID |