Provider Demographics
NPI:1558102715
Name:KULLY CREECH, JAIDEN
Entity type:Individual
Prefix:
First Name:JAIDEN
Middle Name:
Last Name:KULLY CREECH
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 1:2806 S 110TH CT
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68144-4814
Mailing Address - Country:US
Mailing Address - Phone:402-502-8374
Mailing Address - Fax:402-385-7737
Practice Address - Street 1:2806 S 110TH CT
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144-4814
Practice Address - Country:US
Practice Address - Phone:402-502-8374
Practice Address - Fax:402-385-7737
Is Sole Proprietor?:No
Enumeration Date:2024-06-03
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE4629225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist