Provider Demographics
NPI:1255626321
Name:ANGEL-TREJO, JODY LYNN (LIMHP)
Entity type:Individual
Prefix:
First Name:JODY
Middle Name:LYNN
Last Name:ANGEL-TREJO
Suffix:
Gender:F
Credentials:LIMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 W 15TH ST
Mailing Address - Street 2:
Mailing Address - City:KEARNEY
Mailing Address - State:NE
Mailing Address - Zip Code:68845-6763
Mailing Address - Country:US
Mailing Address - Phone:308-236-0500
Mailing Address - Fax:308-237-5225
Practice Address - Street 1:220 W 15TH ST
Practice Address - Street 2:
Practice Address - City:KEARNEY
Practice Address - State:NE
Practice Address - Zip Code:68845-6763
Practice Address - Country:US
Practice Address - Phone:308-236-0500
Practice Address - Fax:308-237-5225
Is Sole Proprietor?:No
Enumeration Date:2011-06-16
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE9418101YM0800X
NE1405101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10026643700Medicaid