Provider Demographics
NPI:1124182845
Name:MONTAG, JACQUIE (NP)
Entity Type:Individual
Prefix:
First Name:JACQUIE
Middle Name:
Last Name:MONTAG
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 N 117TH AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68164-3483
Mailing Address - Country:US
Mailing Address - Phone:402-431-4711
Mailing Address - Fax:402-431-0361
Practice Address - Street 1:2301 N 117TH AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68164-3483
Practice Address - Country:US
Practice Address - Phone:402-431-4711
Practice Address - Fax:402-431-0361
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2011-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE48090163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE48090OtherLICENSE