Provider Demographics
NPI:1730502279
Name:RURAK, JACKIE (JACK) DUWAYNE (ATP #64040)
Entity Type:Individual
Prefix:MR
First Name:JACKIE (JACK)
Middle Name:DUWAYNE
Last Name:RURAK
Suffix:
Gender:M
Credentials:ATP #64040
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 N NOLAN RIVER RD
Mailing Address - Street 2:
Mailing Address - City:CLEBURNE
Mailing Address - State:TX
Mailing Address - Zip Code:76033-7008
Mailing Address - Country:US
Mailing Address - Phone:817-645-4718
Mailing Address - Fax:817-641-2960
Practice Address - Street 1:604 N NOLAN RIVER RD
Practice Address - Street 2:
Practice Address - City:CLEBURNE
Practice Address - State:TX
Practice Address - Zip Code:76033-7008
Practice Address - Country:US
Practice Address - Phone:817-645-4718
Practice Address - Fax:817-641-2960
Is Sole Proprietor?:No
Enumeration Date:2014-02-03
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX015900601Medicaid
TX0167820001Medicare NSC