Provider Demographics
NPI:1376177741
Name:HOGAN, PAYTON JIBRI (MS, LIMHP)
Entity Type:Individual
Prefix:
First Name:PAYTON
Middle Name:JIBRI
Last Name:HOGAN
Suffix:
Gender:M
Credentials:MS, LIMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5858 WENNINGHOFF RD STE 2
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68134-1911
Mailing Address - Country:US
Mailing Address - Phone:402-512-3475
Mailing Address - Fax:402-206-2759
Practice Address - Street 1:5858 WENNINGHOFF RD STE 2
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68134-1911
Practice Address - Country:US
Practice Address - Phone:402-512-3475
Practice Address - Fax:402-206-2759
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-25
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2953101YM0800X
NEP-1765101YA0400X
NE12129101YM0800X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10027143800Medicaid