Provider Demographics
NPI:1790857811
Name:CARLSON, JACK EVERIE (LIMHP LPC)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:EVERIE
Last Name:CARLSON
Suffix:
Gender:M
Credentials:LIMHP LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 SO 50TH ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68506
Mailing Address - Country:US
Mailing Address - Phone:402-643-2800
Mailing Address - Fax:402-643-4048
Practice Address - Street 1:459 S 6TH ST
Practice Address - Street 2:BLUE VALLEY BEHAVIORAL HEALTH
Practice Address - City:SEWARD
Practice Address - State:NE
Practice Address - Zip Code:68434-2405
Practice Address - Country:US
Practice Address - Phone:402-643-3343
Practice Address - Fax:402-643-4048
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2275101YM0800X
NE563101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025208600Medicaid
NE470528515-06Medicaid
NE470528515-09Medicaid
NE10025207900Medicaid
NE470528515-00Medicaid
NE470528515-14Medicaid
NE470528515-15Medicaid
NE47052851505Medicaid
237457OtherMIDLANDS CHOICE
NE470528515-13Medicaid
NE470528515-01Medicaid
NE470528515-02Medicaid
NE470528515-03Medicaid
NE470528515-05Medicaid
NE470528515-08Medicaid
NE470528515-17Medicaid
NE470528515-82Medicaid
NE10025668200Medicaid
NE470528515-04Medicaid
NE470528515-07Medicaid
NE470528515-10Medicaid
NC84591OtherBCBS