Healthcare Provider Details

I. General information

NPI: 1508865007
Provider Name (Legal Business Name): SARA JUANITA JUMPING EAGLE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2005
Last Update Date: 12/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 N. RIVER RD. FORT YATES IHS HOSPITAL/CLINIC
FT. YATES ND
58538
US

IV. Provider business mailing address

10 NORTH RIVER ROAD
FORT YATES ND
58538
US

V. Phone/Fax

Practice location:
  • Phone: 701-854-3831
  • Fax: 701-854-7399
Mailing address:
  • Phone: 701-854-3831
  • Fax: 701-854-7399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number11019
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: