Provider Demographics
NPI:1639312218
Name:WARNER, JEROMY A (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JEROMY
Middle Name:A
Last Name:WARNER
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:835 S BURLINGTON AVE
Mailing Address - Street 2:SUITE 108
Mailing Address - City:HASTINGS
Mailing Address - State:NE
Mailing Address - Zip Code:68901-6960
Mailing Address - Country:US
Mailing Address - Phone:402-463-7711
Mailing Address - Fax:402-461-5099
Practice Address - Street 1:835 S BURLINGTON AVE
Practice Address - Street 2:SUITE 108
Practice Address - City:HASTINGS
Practice Address - State:NE
Practice Address - Zip Code:68901-6960
Practice Address - Country:US
Practice Address - Phone:402-463-7711
Practice Address - Fax:402-461-5099
Is Sole Proprietor?:No
Enumeration Date:2009-04-13
Last Update Date:2010-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE740103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE7596OtherPROVISIONAL MENTAL HEALTH PRACTITIONER
NE740OtherSTATE LICENSE PSYCHOLOGIST
NE47037877935Medicaid
NE330OtherPROVISIONALLY LICENSED PSYCHOLOGIST