Provider Demographics
NPI:1316009475
Name:HEARTLAND FAMILY SERVICE
Entity Type:Organization
Organization Name:HEARTLAND FAMILY SERVICE
Other - Org Name:FAMILY SERVICE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:JEANETTA
Authorized Official - Suffix:
Authorized Official - Credentials:MBA, MSW
Authorized Official - Phone:402-552-7402
Mailing Address - Street 1:2101 S 42ND ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68105-2909
Mailing Address - Country:US
Mailing Address - Phone:402-553-3000
Mailing Address - Fax:402-553-3133
Practice Address - Street 1:515 E BROADWAY
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503
Practice Address - Country:US
Practice Address - Phone:712-322-1407
Practice Address - Fax:712-322-6833
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2010-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE261QM0801X, 261QM0850X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE=========Medicaid
IAIB1256Medicare PIN