Provider Demographics
NPI:1831273788
Name:PEDERSEN, JODY A (APRN)
Entity type:Individual
Prefix:
First Name:JODY
Middle Name:A
Last Name:PEDERSEN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:982035 NEBRASKA MEDICAL CTR
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68198-2035
Mailing Address - Country:US
Mailing Address - Phone:402-559-9604
Mailing Address - Fax:402-559-7779
Practice Address - Street 1:982035 NEBRASKA MEDICAL CTR
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68198-2035
Practice Address - Country:US
Practice Address - Phone:402-559-9604
Practice Address - Fax:402-559-7779
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE110587363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE37664OtherBCBSN
NE37664OtherBCBSN