Provider Demographics
NPI:1649938960
Name:JACK-LOVE, MICHELE (LIMHP)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:
Last Name:JACK-LOVE
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 1:18644 WEIR CIR
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68135-3510
Mailing Address - Country:US
Mailing Address - Phone:402-509-3126
Mailing Address - Fax:
Practice Address - Street 1:10050 REGENCY CIR STE 509
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-3783
Practice Address - Country:US
Practice Address - Phone:402-906-2611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-03
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2946101YM0800X
NE12189101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health