Provider Demographics
NPI:1356146153
Name:PODLISKA, JAY DEREK
Entity type:Individual
Prefix:
First Name:JAY
Middle Name:DEREK
Last Name:PODLISKA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 S SUNSET ST LOT 8
Mailing Address - Street 2:
Mailing Address - City:PIERCE
Mailing Address - State:NE
Mailing Address - Zip Code:68767-1818
Mailing Address - Country:US
Mailing Address - Phone:402-270-6794
Mailing Address - Fax:
Practice Address - Street 1:501 S SUNSET ST LOT 8
Practice Address - Street 2:
Practice Address - City:PIERCE
Practice Address - State:NE
Practice Address - Zip Code:68767-1818
Practice Address - Country:US
Practice Address - Phone:402-270-6794
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-17
Last Update Date:2025-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE372500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372500000XNursing Service Related ProvidersChore Provider