Provider Demographics
NPI:1407627938
Name:JURASEVICH, AUTUMN BLYTHE
Entity Type:Individual
Prefix:
First Name:AUTUMN
Middle Name:BLYTHE
Last Name:JURASEVICH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 980
Mailing Address - Street 2:
Mailing Address - City:PRINCE FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:20678-0980
Mailing Address - Country:US
Mailing Address - Phone:410-535-3079
Mailing Address - Fax:410-535-2220
Practice Address - Street 1:975 SOLOMONS ISLAND RD N STE 119
Practice Address - Street 2:
Practice Address - City:PRINCE FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:20678-3917
Practice Address - Country:US
Practice Address - Phone:410-535-5400
Practice Address - Fax:410-535-2220
Is Sole Proprietor?:No
Enumeration Date:2024-01-12
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional