Provider Demographics
NPI:1821205980
Name:GILFILLAN, JODY RENEE (MAA,LADC)
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:RENEE
Last Name:GILFILLAN
Suffix:
Gender:F
Credentials:MAA,LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3119 S 44TH ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68506-3331
Mailing Address - Country:US
Mailing Address - Phone:402-488-9615
Mailing Address - Fax:
Practice Address - Street 1:421 S 9TH ST
Practice Address - Street 2:SUITE 205
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68508-2261
Practice Address - Country:US
Practice Address - Phone:402-601-4289
Practice Address - Fax:402-475-7541
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2016-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE146101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025470200Medicaid