OESTMANN, JERRY L (PHD)

Provider Demographics

• NPI: 1790858959
• Name: OESTMANN, JERRY L (PHD)
• Entity Type: Individual
• Prefix: DR
• First Name: JERRY
• Middle Name: L
• Last Name: OESTMANN
• Gender: M
• Credentials: PHD
• Mailing Address - Street 1: 1730 DUNLAWTON AVE
• Mailing Address - Street 2: SUITE 3
• Mailing Address - City: PORT ORANGE
• Mailing Address - State: FL
• Mailing Address - Zip Code: 32127-8985
• Mailing Address - Country: US
• Mailing Address - Phone: 386-957-3905
• Mailing Address - Fax: 386-402-8992
• Practice Address - Street 1: 1730 DUNLAWTON AVE
• Practice Address - Street 2: SUITE 3
• Practice Address - City: PORT ORANGE
• Practice Address - State: FL
• Practice Address - Zip Code: 32127-8985
• Practice Address - Country: US
• Practice Address - Phone: 386-957-3905
• Practice Address - Fax: 386-402-8992
• Is Sole Proprietor?: Yes
• Enumeration Date: 2006-11-16
• Last Update Date: 2019-02-13

Provider Licenses

State	License ID	Taxonomies
NE	188	101YP2500X
NE	396	101YM0800X
NE	620	103T00000X
FL	PY9026	103T00000X

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization
Yes	103T00000X	Behavioral Health & Social Service Providers	Psychologist
No	101YP2500X	Behavioral Health & Social Service Providers	Counselor	Professional
No	101YM0800X	Behavioral Health & Social Service Providers	Counselor	Mental Health

Provider Identifiers

State	Identifier ID	ID Type	Issuer
NE	47052851500	Medicaid
NE	47052851509	Medicaid
NE	68505B002	Other	TRICARE
NE	345680000	Other	MAGELLAN MIS ADOL GT
NE	47075636998	Medicaid
NE	80023	Other	BLUE CROSS & BLUE SHIELD
NE	10025208600	Medicaid
NE	81118	Other	BCBS INDIVIDUAL PROVIDER NUMBER
NE	10025208000	Medicaid
NE	250307	Other	MIDLANDS INS
NE	098935	Other	MEDICARE FSI PTAN GROUP NUMBER
NE	1002550710	Medicaid
NE	10025668200	Medicaid
NE	345680000	Other	MAGELLAN MIS GT SITE
NE	349507000	Other	MAGELLAN MIS WOMEN'S GT
NE	47052851502	Medicaid
NE	47052851503	Medicaid
NE	85731	Other	BCBS
NE	47052851581	Medicaid
NE	10025208700	Medicaid
NE	47052851504	Medicaid
NE	47075636930	Medicaid
NE	47052851503	Medicaid
NE	81118	Other	BCBS INDIVIDUAL PROVIDER NUMBER
NE	098935001	Medicare PIN
NE	NA1268	Medicare PIN
NE	098127004	Medicare PIN
NE	47052851581	Medicaid
NE	47075636930	Medicaid
NE	NA1267	Medicare PIN