Basic Information
Provider Information
NPI: 1003299827
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: TICHENOR
FirstName: JORDAN
MiddleName:  
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Credential:  
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Mailing Information
Address1: 988102 NEBRASKA MEDICAL CTR
Address2:  
City: OMAHA
State: NE
PostalCode: 681988102
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 8604 GILES RD
Address2:  
City: LA VISTA
State: NE
PostalCode: 68128
CountryCode: US
TelephoneNumber: 4025596637
FaxNumber: 4025598333
Other Information
ProviderEnumerationDate: 06/30/2015
LastUpdateDate: 09/07/2018
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
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IsSoleProprietor: N
IsOrganizationSubpart:  
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AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207R00000X1770NEY Allopathic & Osteopathic PhysiciansInternal Medicine 
207R00000XR10373IAN Allopathic & Osteopathic PhysiciansInternal Medicine 

No ID Information.


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