Provider Demographics
NPI:1164860268
Name:MICHAELIS, JENNIFER R (PA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:R
Last Name:MICHAELIS
Suffix:
Gender:F
Credentials:PA
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 1:16120 W DODGE RD
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68118-2049
Practice Address - Country:US
Practice Address - Phone:402-354-0707
Practice Address - Fax:402-354-0711
Is Sole Proprietor?:No
Enumeration Date:2013-06-11
Last Update Date:2015-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1825363A00000X
IA074838363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47068731742Medicaid
NE47068731751Medicaid
NE47068731751Medicaid