Provider Demographics
NPI:1588641385
Name:JURRENS, TRACI L (MD)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:L
Last Name:JURRENS
Suffix:
Gender:F
Credentials:MD
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 3755
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68103-0755
Mailing Address - Country:US
Mailing Address - Phone:402-354-2100
Mailing Address - Fax:402-354-6171
Practice Address - Street 1:1120 N 103RD PLZ
Practice Address - Street 2:SUITE 100
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-1114
Practice Address - Country:US
Practice Address - Phone:402-391-5055
Practice Address - Fax:402-384-4202
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2015-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE22554207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE100264481-00Medicaid
IA1588641385Medicaid
NE100264481-00Medicaid
IAENROLLEDMedicaid
I00431Medicare UPIN
MN060002182Medicare PIN