Provider Demographics
NPI:1659336675
Name:VIDRA, JEFFREY M (LMHP, CPC)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:M
Last Name:VIDRA
Suffix:
Gender:M
Credentials:LMHP, CPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 W NORFOLK AVE
Mailing Address - Street 2:STE 201
Mailing Address - City:NORFOLK
Mailing Address - State:NE
Mailing Address - Zip Code:68701-5401
Mailing Address - Country:US
Mailing Address - Phone:402-379-2030
Mailing Address - Fax:402-379-3933
Practice Address - Street 1:333 W NORFOLK AVE
Practice Address - Street 2:STE 201
Practice Address - City:NORFOLK
Practice Address - State:NE
Practice Address - Zip Code:68701-5401
Practice Address - Country:US
Practice Address - Phone:402-379-2030
Practice Address - Fax:402-379-3933
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1170101YP2500X
NE2041101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE113522OtherOPTUM LIFE ERA
NE39189435426Medicaid
NE24147OtherMIDLANDS CHOICE
NE84322OtherBC/BS