Provider Demographics
NPI:1376705285
Name:JUREK, GINA MARIE (COT)
Entity Type:Individual
Prefix:MRS
First Name:GINA
Middle Name:MARIE
Last Name:JUREK
Suffix:
Gender:F
Credentials:COT
Other - Prefix:MRS
Other - First Name:GINA
Other - Middle Name:MARIE
Other - Last Name:BISSETTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COT
Mailing Address - Street 1:PO BOX 620577
Mailing Address - Street 2:BLDG. 6901 FARREL ROAD
Mailing Address - City:FORT RUCKER
Mailing Address - State:AL
Mailing Address - Zip Code:36362-0577
Mailing Address - Country:US
Mailing Address - Phone:334-255-6807
Mailing Address - Fax:334-255-6873
Practice Address - Street 1:BLDG. 6901 FARREL ROAD
Practice Address - Street 2:
Practice Address - City:FORT RUCKER
Practice Address - State:AL
Practice Address - Zip Code:36362-0577
Practice Address - Country:US
Practice Address - Phone:334-255-6807
Practice Address - Fax:334-255-6873
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-01
Last Update Date:2013-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN79518156FX1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1100XEye and Vision Services ProvidersTechnician/TechnologistOphthalmic