Provider Demographics
NPI:1396096400
Name:ERB, JACKIE E
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:E
Last Name:ERB
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 1:1020 21ST ST
Mailing Address - Street 2:
Mailing Address - City:GOTHENBURG
Mailing Address - State:NE
Mailing Address - Zip Code:69138-2501
Mailing Address - Country:US
Mailing Address - Phone:402-318-1735
Mailing Address - Fax:
Practice Address - Street 1:910 20TH ST
Practice Address - Street 2:
Practice Address - City:GOTHENBURG
Practice Address - State:NE
Practice Address - Zip Code:69138-1237
Practice Address - Country:US
Practice Address - Phone:308-537-3661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-28
Last Update Date:2015-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201242161RN390200000X
NE101285367500000X
NE69233163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No163W00000XNursing Service ProvidersRegistered Nurse