Basic Information
| Provider Information | |||||||||
| NPI: | 1235309022 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VLCEK | ||||||||
| FirstName: | JEANNE | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PT, DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WALLER | ||||||||
| OtherFirstName: | JEANNE | ||||||||
| OtherMiddleName: | S | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PT, DPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 11151 PROSPECT ST | ||||||||
| Address2: | |||||||||
| City: | PAPILLION | ||||||||
| State: | NE | ||||||||
| PostalCode: | 680463873 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4022107177 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8642 F ST | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681271639 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023939390 | ||||||||
| FaxNumber: | 4023939388 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2008 | ||||||||
| LastUpdateDate: | 10/18/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2629 | NE | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 2629 | 01 | NE | STATE LICENSE | OTHER |