Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207R00000X | Internist | 1770 | NE |
Y | 111NI0900X | Internist | 1770 | NE |
N | 207R00000X | Internist | R10373 | IA |
N | 111NI0900X | Internist | R10373 | IA |
NPI | 1003299827 |
---|---|
Provider Name | Jordan Tichenor |
First Address | Omaha, NE 68198-8102 |
Second Address | La Vista, NE 68128 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/06/2015 |
Last Update Date | 07/09/2018 |