Healthcare Provider Details

I. General information

NPI: 1619442803
Provider Name (Legal Business Name): SAMANTHA J JIRAK DNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SAMANTHA JO FERGUSON DNP

II. Dates (important events)

Enumeration Date: 10/04/2018
Last Update Date: 12/01/2020
Certification Date: 12/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 N 9TH AVE
VINTON IA
52349-2254
US

IV. Provider business mailing address

504 N 9TH AVE
VINTON IA
52349-2254
US

V. Phone/Fax

Practice location:
  • Phone: 319-472-6300
  • Fax:
Mailing address:
  • Phone: 319-472-6300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA136122
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberG136122
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: