Provider Demographics
NPI:1790732600
Name:JURACEK, AMY S (CNP)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:S
Last Name:JURACEK
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:S
Other - Last Name:WITT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNP
Mailing Address - Street 1:814 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:BURKE
Mailing Address - State:SD
Mailing Address - Zip Code:57523-0358
Mailing Address - Country:US
Mailing Address - Phone:605-775-2631
Mailing Address - Fax:
Practice Address - Street 1:809 JACKSON ST
Practice Address - Street 2:
Practice Address - City:BURKE
Practice Address - State:SD
Practice Address - Zip Code:57523-2065
Practice Address - Country:US
Practice Address - Phone:605-775-2631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDCP000467363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
0851370001OtherDME
SD6829160Medicaid
SD6829160Medicaid
SD101414Medicare PIN