Provider Demographics
NPI:1811187701
Name:PROBST, JACQUELINE DEE (COTA/L)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:DEE
Last Name:PROBST
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 N 10TH ST
Mailing Address - Street 2:BOX 278
Mailing Address - City:BEATRICE
Mailing Address - State:NE
Mailing Address - Zip Code:68310-2039
Mailing Address - Country:US
Mailing Address - Phone:402-223-7309
Mailing Address - Fax:
Practice Address - Street 1:1110 N 10TH ST
Practice Address - Street 2:BOX 278
Practice Address - City:BEATRICE
Practice Address - State:NE
Practice Address - Zip Code:68310-2039
Practice Address - Country:US
Practice Address - Phone:402-223-7309
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-27
Last Update Date:2007-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE35224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant