Provider Demographics
NPI:1952280208
Name:ANTHONY, JONATHAN BLAKE (ACNPC-AG)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:BLAKE
Last Name:ANTHONY
Suffix:
Gender:M
Credentials:ACNPC-AG
Other - Prefix:
Other - First Name:BLAKE
Other - Middle Name:
Other - Last Name:ANTHONY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PARAMEDIC
Mailing Address - Street 1:7440 S 91ST ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68526-9797
Mailing Address - Country:US
Mailing Address - Phone:402-564-7756
Mailing Address - Fax:
Practice Address - Street 1:4508 38TH ST STE 157
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:NE
Practice Address - Zip Code:68601-1668
Practice Address - Country:US
Practice Address - Phone:402-564-7756
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-30
Last Update Date:2025-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE116265363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Single Specialty