Provider Demographics
NPI:1184345241
Name:JACKSON, CALLIE RAE
Entity type:Individual
Prefix:
First Name:CALLIE
Middle Name:RAE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10520 S 123RD AVE
Mailing Address - Street 2:
Mailing Address - City:PAPILLION
Mailing Address - State:NE
Mailing Address - Zip Code:68046-4393
Mailing Address - Country:US
Mailing Address - Phone:402-514-3650
Mailing Address - Fax:
Practice Address - Street 1:10520 S 123RD AVE
Practice Address - Street 2:
Practice Address - City:PAPILLION
Practice Address - State:NE
Practice Address - Zip Code:68046-4393
Practice Address - Country:US
Practice Address - Phone:402-514-3650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-07
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE3747P1801XMedicaid