Provider Demographics
NPI:1255577102
Name:JIZBA, THERESA A (APRN)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:A
Last Name:JIZBA
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:A
Other - Last Name:HACKMANN
Other - Suffix:
Other - Last Name Type:Former Name
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:402-354-2917
Practice Address - Fax:402-354-3160
Is Sole Proprietor?:No
Enumeration Date:2008-12-24
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE111244363L00000X
AZAP4182363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47037660432Medicaid
IA1255577102Medicaid
MNP00759940OtherRAILROAD MEDICARE
MNP00759940OtherRAILROAD MEDICARE
MNENROLLEDMedicaid