Provider Demographics
NPI:1346397338
Name:ANDERSON, JACQUELINE ANNE (EDS, LMHP, LPC,)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:ANNE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:EDS, LMHP, LPC,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 1 BOX 99
Mailing Address - Street 2:
Mailing Address - City:GOTHENBURG
Mailing Address - State:NE
Mailing Address - Zip Code:69138-9607
Mailing Address - Country:US
Mailing Address - Phone:308-537-2585
Mailing Address - Fax:308-537-2585
Practice Address - Street 1:408 10TH ST
Practice Address - Street 2:
Practice Address - City:GOTHENBURG
Practice Address - State:NE
Practice Address - Zip Code:69138-1922
Practice Address - Country:US
Practice Address - Phone:308-529-0821
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2756101YM0800X
NE1465101YP2500X
NE31858103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025003500Medicaid