Provider Demographics
NPI:1538811211
Name:LARA, JENNIFER CHARLENE (PMLHP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:CHARLENE
Last Name:LARA
Suffix:
Gender:F
Credentials:PMLHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8922 CUMING ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68114-2732
Mailing Address - Country:US
Mailing Address - Phone:402-926-4373
Mailing Address - Fax:
Practice Address - Street 1:8922 CUMING ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-2732
Practice Address - Country:US
Practice Address - Phone:402-727-1592
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-24
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE11896103TC1900X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE11896Medicaid