Provider Demographics
NPI:1902857733
Name:THEOBALD, JANE M (MD)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:M
Last Name:THEOBALD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2797
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68103-2797
Mailing Address - Country:US
Mailing Address - Phone:402-354-4230
Mailing Address - Fax:402-354-6171
Practice Address - Street 1:8303 DODGE ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-4108
Practice Address - Country:US
Practice Address - Phone:402-354-8350
Practice Address - Fax:402-354-8355
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2013-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE226562084P0800X
IA362982084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0724039Medicaid
NE47037660433Medicaid
IA1902857733Medicaid
IA0724039Medicaid
NE47037660433Medicaid