Provider Demographics
NPI:1003058280
Name:STONE, JENNIFER D (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:D
Last Name:STONE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3755
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68103-0755
Mailing Address - Country:US
Mailing Address - Phone:402-354-2100
Mailing Address - Fax:402-354-2155
Practice Address - Street 1:1 EDMUNDSON PL
Practice Address - Street 2:SUITE 310
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503-4658
Practice Address - Country:US
Practice Address - Phone:712-396-4280
Practice Address - Fax:712-396-4180
Is Sole Proprietor?:No
Enumeration Date:2009-04-02
Last Update Date:2014-04-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IA34707207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1003058280Medicaid
NE470687317-12Medicaid
NE470687317-12Medicaid
IA058970036Medicare PIN