Basic Information
| Provider Information | |||||||||
| NPI: | 1649493933 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JERICHO COUNSELING ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1941 S 42ND ST STE 538 | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681052945 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023447000 | ||||||||
| FaxNumber: | 4023448089 | ||||||||
| Practice Location | |||||||||
| Address1: | 1941 S 42ND ST STE 538 | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681052945 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023447000 | ||||||||
| FaxNumber: | 4023448089 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2007 | ||||||||
| LastUpdateDate: | 06/13/2008 | ||||||||
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| AuthorizedOfficialLastName: | DUNCAN | ||||||||
| AuthorizedOfficialFirstName: | LARRY | ||||||||
| AuthorizedOfficialMiddleName: | JAMES | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE | ||||||||
| AuthorizedOfficialTelephone: | 4023447000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MHR, LADC, LMHP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 385 | NE | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | 2166 | NE | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 100254608-00 | 05 | NE | MEDICAID |