Provider Demographics
NPI:1003488446
Name:O'NEILL, JACOB DANIEL
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:DANIEL
Last Name:O'NEILL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2671 N 97TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68134-5368
Mailing Address - Country:US
Mailing Address - Phone:402-714-5621
Mailing Address - Fax:
Practice Address - Street 1:20800 W MAPLE RD
Practice Address - Street 2:
Practice Address - City:ELKHORN
Practice Address - State:NE
Practice Address - Zip Code:68022-5108
Practice Address - Country:US
Practice Address - Phone:866-748-3655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-14
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant