Provider Demographics
NPI:1346605250
Name:COPENHARVE, JESSE
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:COPENHARVE
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 1:6809 N 68TH PLZ
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68152-2117
Mailing Address - Country:US
Mailing Address - Phone:402-572-2134
Mailing Address - Fax:
Practice Address - Street 1:6809 N 68TH PLZ
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68152-2117
Practice Address - Country:US
Practice Address - Phone:402-572-2134
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-18
Last Update Date:2015-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1283225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant