Provider Demographics
NPI:1619442803
Name:JIRAK, SAMANTHA J (DNP)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:J
Last Name:JIRAK
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:JO
Other - Last Name:FERGUSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DNP
Mailing Address - Street 1:504 N 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:VINTON
Mailing Address - State:IA
Mailing Address - Zip Code:52349-2254
Mailing Address - Country:US
Mailing Address - Phone:319-472-6300
Mailing Address - Fax:
Practice Address - Street 1:504 N 9TH AVE
Practice Address - Street 2:
Practice Address - City:VINTON
Practice Address - State:IA
Practice Address - Zip Code:52349-2254
Practice Address - Country:US
Practice Address - Phone:319-472-6300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-04
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAG136122363LP0808X
IAA136122363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health